Ivy Creek Healthcare & Wellness Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 115 Bridge St., San Gabriel, California 91775
- CMS Provider Number
- 055441
- Inspections on file
- 26
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ivy Creek Healthcare & Wellness Centre during CMS and state inspections, most recent first.
A resident with a history of severe mental health conditions exhibited multiple episodes of aggressive behavior, including physically striking another resident, while on Depakote. Despite care plan and physician orders to monitor and report behavioral fluctuations, staff did not consistently notify the physician or document the effectiveness of non-pharmacological interventions. Facility policies requiring monitoring, documentation, and interdisciplinary collaboration were not followed, resulting in unaddressed behavioral escalation and resident-to-resident aggression.
Two residents on dialysis with physician-ordered fluid restrictions consistently received fluids in excess of their prescribed limits. Staff did not consistently educate the residents, notify the physician, or convene the IDT as required by facility policy, and intake and output records showed repeated noncompliance with care plans.
Three residents did not receive their scheduled medications within the facility's required one-hour administration window. An LPN administered muscle relaxants, blood pressure medications, and other critical drugs late to residents with complex medical histories and cognitive impairments, contrary to facility policy and procedures.
Surveyors identified a medication error rate of over 30% when multiple medications were administered late to three residents with complex medical conditions. Despite facility policy requiring medications to be given within a one-hour window of the scheduled time, staff administered several medications outside this timeframe, resulting in a deficiency.
Three dumpsters outside the facility were found overflowing with empty boxes and kitchen trash, as confirmed by the Dietary Service Supervisor and Director of Nursing. Facility policy requires food waste to be placed in covered garbage cans, but observations and staff interviews revealed that dumpsters were not closed or managed properly, increasing the risk of contamination and pest attraction.
Staff did not consistently monitor or ensure that washing machines reached the required high temperatures for disinfecting soiled linens, with water temperatures recorded well below policy standards and broken equipment left unaddressed. This resulted in multiple loads of laundry being washed at insufficient temperatures, contrary to facility infection control policy.
A resident who was bed-confined and severely cognitively impaired was observed having their briefs changed by a CNA without the privacy curtain or door being closed. Interviews with staff and review of facility policy confirmed that privacy should have been provided during personal care to maintain dignity and respect.
Two residents did not have comprehensive, individualized care plans developed or implemented as required, despite having significant medical needs such as anticoagulant therapy for PVD and total assistance required for ADLs and bowel incontinence. Staff and nursing leadership confirmed that care plans addressing these needs were missing, which could impact the delivery of appropriate care.
A resident with significant physical and cognitive impairments, who was dependent on staff for oral hygiene and had no natural teeth, received a repaired upper denture, but the care plan was not updated to reflect this change. Staff confirmed the resident wore both upper and lower dentures daily, yet the care plan continued to reference the broken denture, contrary to facility policy requiring care plan updates after assessments and changes in condition.
A resident with a history of skin tears and cognitive impairment was not wearing Geri sleeves as ordered by the physician, despite a care plan and facility policy requiring their use to prevent further injury. During observation, the LVN could not locate the sleeves, and both the LVN and DON confirmed the order should have been followed.
A resident with end stage renal disease and an AV shunt in the left arm had multiple blood pressure checks incorrectly documented as being performed on the left arm by an LVN, despite orders prohibiting this due to the shunt. The resident confirmed blood pressure was only taken on the right arm, and the DON highlighted the need for accurate documentation to prevent misinterpretation by staff.
A resident with cognitive impairment and multiple medical conditions was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Staff and the DON confirmed the call light should have been within reach to allow the resident to request assistance.
A resident with severe cognitive impairment and bed confinement was found in a room where the linen bin was overflowing with used linen, unlined with plastic, and left open. Both the DON and RN Supervisor confirmed this was against facility policy and infection control standards, resulting in an unsanitary environment.
Four resident rooms were found to be below the required 80 square feet per resident in multiple occupancy rooms. Despite this, residents and staff reported no issues with space for mobility or care, and observations confirmed adequate maneuverability and care provision. The facility had submitted a waiver for these rooms, and the department recommended its approval.
A resident with pneumonia did not have two doses of IV antibiotics documented in the MAR, as required by the facility's policy. Two RNs administered the medication but failed to sign the MAR, which was confirmed by the DON. This lack of documentation could lead to medication errors.
The facility failed to provide appropriate communication boards for two residents with language barriers, leading to potential miscommunication and unmet needs. One resident had a board in the wrong language and out of reach, while another had no board at all. Staff confirmed these issues, which were contrary to the facility's policy on accommodating communication needs.
A resident with cognitive impairment accused a CNA of abuse, but the facility failed to report the allegation within the required two-hour timeframe. The incident involved a skin discoloration on the resident's hand, initially attributed to a blood draw. The LVN informed the DON, who misread the message, delaying the report to the CDPH. The facility's policy mandates prompt reporting to ensure resident safety.
The facility failed to provide a homelike environment for three residents. Two residents had rooms with peeling paint and unmaintained baseboards, while another resident's room had a staff member's beverage left on a hand sanitizer dispenser. The DON and Maintenance Assistant acknowledged these issues, which were not addressed in a timely manner.
The facility failed to ensure licensed nurses administered oxygen to two residents as per their care plans and physician orders, leading to potential risks in their respiratory care. CNAs were observed performing tasks that should have been handled by licensed nurses, contrary to facility policies.
The facility failed to ensure proper food storage and labeling, including unlabeled red fruit Jello, apple sauce cups, rice noodles, and garlic bags, as well as spoiled cilantro mixed with carrots and mislabeled chorizo containing bacon. These deficiencies were confirmed through observations and interviews with the Dietary Staff Supervisor and Dietary Aid.
The facility failed to maintain dignity and respect for two residents during feeding. Both residents, who have severe cognitive impairments and dysphagia, were fed by CNAs who were standing, causing discomfort and a lack of respect. Facility policies require staff to sit at eye level while feeding residents to ensure dignity.
The facility failed to ensure call lights were within reach for three residents, including those with severe cognitive impairments and vision issues, leading to potential delays in receiving necessary assistance.
The nursing staff failed to maintain the privacy and confidentiality of a resident's medical records by leaving the computer screen unattended multiple times, exposing sensitive information to passersby. The DON and Administrator confirmed that staff should log off and close computer screens before leaving the nursing station.
The facility failed to ensure that a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS) and Care Area Assessment (CAA) for a resident with type 2 diabetes mellitus and moderate cognitive impairment. Instead, a Licensed Vocational Nurse (LVN) signed the MDS, which was against the facility's policy and CMS guidelines, potentially leading to an incomplete assessment and inaccurate care planning.
The facility failed to follow the care plan for a resident on oxygen therapy, who was observed lying flat despite needing the head of the bed elevated. This oversight, confirmed by an LVN and the DON, could lead to serious health issues for the resident, who has severe cognitive impairment and respiratory conditions.
A resident with severe cognitive impairment and dependency was found with white crust on the eyelids and brownish stains around the mouth, indicating a failure by the facility to provide necessary hygiene care. Staff acknowledged the deficiency, and facility policies on hygiene and resident rights were not followed.
The facility failed to ensure that a resident with Alzheimer's Disease had an abdominal binder to prevent g-tube dislodgement and did not reassess another resident's diabetic foot ulcer as per the care plan, leading to potential health risks.
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident receiving hospice services by not maintaining hospice nursing and visitation notes in the resident's medical record. The resident had severe cognitive impairment and was dependent on assistance for daily activities, with specific hospice visit frequencies ordered by a physician. The Director of Nursing confirmed the deficiency but was unsure who was responsible for ensuring complete documentation.
The facility failed to enforce infection control policies, including hand hygiene by CNAs, proper handling of nasal cannula tubing, and disinfecting laundry washers after each use. These lapses were observed during resident care and laundry handling, posing a risk of infection.
The facility failed to maintain kitchen equipment in safe operating condition when the kitchen burners did not ignite properly. The cook used a piece of paper to ignite the burner, which led to burns. The Dietary Staff Supervisor acknowledged the danger and mentioned that maintenance is scheduled monthly or as needed. The Maintenance Assistant was unaware of the issue, despite policies requiring safe and operable equipment.
The facility failed to ensure that four resident bedrooms met the federal regulation requirement of at least 80 square feet per resident in multiple resident bedrooms. Rooms 24, 26, 28, and 44 were found to be below the required space per resident, but the facility submitted a waiver request indicating adequate space for nursing care.
Failure to Address and Report Escalating Behavioral Disturbances
Penalty
Summary
The facility failed to adequately address and manage the recurrent behavioral fluctuations of a resident with a history of bipolar disorder, delusional disorder, psychosis, and dementia, who was prescribed Depakote for mood stabilization. Despite physician orders and care plan directives to monitor and document episodes of behavioral disturbances, including verbally aggressive outbursts and diminished interest in activities of daily living (ADLs), the facility did not consistently notify the physician of escalating behaviors or document the effectiveness of non-pharmacological interventions (NPI). The resident experienced 11 incidents of behavioral disturbances within a short period, yet there was no evidence that the physician was informed or that the care plan interventions were fully implemented and evaluated as required. On one occasion, the resident physically struck another resident, resulting in the latter being hit on the left leg. Staff interviews confirmed that the aggressive behaviors were observed and that there was an expectation to notify the physician and document interventions, but this was not done. The medication administration records (MAR) and behavior monitoring logs indicated gaps in documentation, particularly regarding the use and effectiveness of NPIs prior to administering medication. Additionally, staff acknowledged that the physician should have been notified of the resident's increasing aggression to consider possible changes in medication or further evaluation. Facility policies and procedures required monitoring and reporting of behavioral symptoms and side effects of psychotropic medications, as well as collaboration with the physician and interdisciplinary team when changes in behavior occurred. However, these protocols were not followed, as evidenced by the lack of timely physician notification, incomplete documentation of behavioral episodes, and insufficient evaluation of interventions. This failure to adhere to established care processes contributed to an incident of resident-to-resident aggression and placed residents at risk for harm.
Failure to Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring fluid restrictions as part of their treatment for end stage renal disease (ESRD). For one resident with severe cognitive impairment and multiple comorbidities, including ESRD and diabetes, physician orders and care plans specified a daily fluid restriction of 1200 ml. Despite these orders, intake and output records showed that this resident consistently received fluids in excess of the prescribed limit on the majority of days over two consecutive months. Staff interviews confirmed that the resident was given additional fluids upon request, and there was no evidence that staff consistently educated the resident about the fluid restriction or notified the physician of noncompliance, as required by the care plan and facility policy. Additionally, the resident's noncompliance was not addressed in a timely manner by the Interdisciplinary Team (IDT), and the last documented IDT discussion regarding this issue was several months prior to the survey. A second resident, who was cognitively intact and also dependent on dialysis, had a physician-ordered fluid restriction of 1000 ml per day. Intake and output records revealed that this resident also regularly received fluids exceeding the prescribed limit on most days during the review period. Staff interviews and care plan reviews indicated that nursing and dietary staff did not ensure the division and distribution of fluids according to the care plan, and the resident's intake was not adequately monitored or restricted as ordered. There was no documentation of staff providing education about the risks of noncompliance or notifying the physician when the resident exceeded fluid limits, as required by facility policy. Facility policies reviewed during the survey specified that noncompliance with fluid restrictions should be documented, the physician notified, and the IDT convened to address ongoing issues. However, these protocols were not followed for either resident. Observations confirmed that residents had access to fluids beyond their prescribed limits, and staff interviews revealed a lack of consistent communication and intervention regarding fluid restrictions. These failures resulted in the facility not adhering to physician orders and established care plans for residents on dialysis.
Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
The facility failed to administer medications within the prescribed time frames as indicated by facility policy for three of four sampled residents. For one resident with a history of osteoarthritis, GERD, and thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the allowed one-hour window. This resident was noted to have moderately impaired cognitive skills and required significant assistance with daily activities. Another resident, admitted with obstructive and reflux uropathy, hypertensive heart disease, and dementia, had multiple medications scheduled for administration at 8 AM and 9 AM, including bethanechol, metoprolol, verquvo, eliquis, and entresto. All these medications were administered at 10:26 AM, exceeding the facility's policy of a one-hour window before or after the scheduled time. This resident also had moderately impaired cognitive skills and required varying levels of assistance with daily living activities. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension had orders for amlodipine and clopidogrel to be given at 9 AM, but both were administered at 10:52 AM. This resident required moderate to maximal assistance with daily care. Interviews with nursing staff and the DON confirmed the facility's policy of a one-hour administration window and the importance of timely medication administration. Review of the facility's policy and procedure corroborated these requirements.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with eight medication errors identified out of 26 observed opportunities, resulting in a 30.77% error rate. The errors involved the late administration of prescribed medications to three residents during observed medication passes. The facility's policy and staff interviews confirmed that medications are to be administered within a one-hour window before or after the scheduled time, but this protocol was not followed in multiple instances. For one resident with osteoarthritis, GERD, and a thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the permitted window. Another resident with obstructive and reflux uropathy, hypertensive heart disease, and dementia was scheduled to receive five different medications between 8 AM and 9 AM, but all were administered at 10:26 AM, well past the allowed timeframe. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension was scheduled to receive amlodipine and clopidogrel at 9 AM, but both were given at 10:52 AM. Staff interviews confirmed awareness of the facility's medication administration policy, which requires adherence to the scheduled times for medication administration to ensure consistency and accurate monitoring. Despite this, the observed medication passes did not comply with the policy, resulting in multiple late administrations and a medication error rate significantly above the acceptable threshold.
Improper Disposal and Overflowing Dumpsters
Penalty
Summary
Three dumpsters located on the west side of the facility, near the entrance and parking area, were observed to be overflowing with empty boxes and clear plastic bags containing kitchen trash. This was noted during an observation, and the Dietary Service Supervisor (DSS) confirmed that the dumpsters were overflowing with both empty boxes and kitchen trash. The DSS also stated that all kitchen trash was disposed of in these dumpsters and acknowledged that the dumpsters were not supposed to be overflowing and should be closed properly. Further interviews with the DSS and the Director of Nursing (DON) confirmed that the dumpsters should be fully closed and not overflowing to prevent attracting rodents, flies, and insects, and to reduce the risk of cross-contamination. A review of the facility's Waste Management Policy and Procedure indicated that food waste should be placed in covered garbage and trash cans to reduce the risk of contamination from regulated waste and to ensure proper handling and disposal of all waste.
Failure to Ensure Proper Water Temperature for Laundry Disinfection
Penalty
Summary
Facility staff failed to obtain accurate water temperature readings and did not ensure that the water used to wash soiled linens in both washing machines met the required temperature according to facility policy. During observations and interviews, it was revealed that the laundry staff did not check the thermometer for the water temperature, and the maintenance supervisor confirmed that the thermometer was broken and the water heater was turned off, resulting in water temperatures between 70-80 degrees Fahrenheit. The maintenance supervisor also stated that the water temperature should have been set at 140 degrees Fahrenheit to properly disinfect the linens, but the actual temperature was only between 72-74 degrees Fahrenheit during the washing of two loads of white linens. Further interviews indicated inconsistent practices, as another laundry staff member reported a thermometer reading of 130 degrees Fahrenheit and mentioned checking but not logging a temperature of 146 degrees Fahrenheit earlier that day. The administrator and infection prevention nurse both confirmed that the washing machines should operate at high temperatures to effectively kill bacteria and pathogens on the laundry. Review of the facility's policy confirmed that the hottest available water should be used for washing linens, but this was not consistently followed, as evidenced by the low water temperatures and lack of proper monitoring.
Failure to Provide Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed changing the briefs of a resident without providing adequate privacy, as both the privacy curtain and the door to the resident's room were left open during the procedure. The resident involved had a history of falling, adult failure to thrive, was bed-confined, and was severely cognitively impaired, requiring total assistance for personal and toilet hygiene. The lack of privacy was directly observed by surveyors in the hallway outside the resident's room. Interviews with the CNA involved, another CNA, and the Director of Nursing (DON) confirmed that facility policy and standard practice require staff to provide full privacy by closing both the curtain and the door when performing personal care tasks. The facility's policy on resident rights and quality of life also specifies the importance of promoting and maintaining resident privacy, dignity, and respect during care. The failure to provide privacy during the brief change was contrary to these established policies and procedures.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as required by its own policies and federal regulations. For one resident with a diagnosis of peripheral vascular disease (PVD) and a physician's order for Eliquis 2.5 mg twice daily, there was no care plan addressing the use of this anticoagulant medication. The resident's medical record indicated moderate cognitive impairment and a need for assistance with personal hygiene and toileting, yet the care plan did not reflect interventions or monitoring related to the medication. Both the Director of Nursing and Infection Preventionist Nurse confirmed during interviews that a care plan should have been initiated upon receipt of the medication order to guide staff in providing appropriate care and monitoring for potential side effects. Another resident, admitted with osteoarthritis, GERD, and a thoracic spine fusion, was assessed as being dependent or requiring significant assistance with activities of daily living (ADLs) such as bathing, dressing, toileting, and was always incontinent of bowel. Despite these findings on the Minimum Data Set (MDS) and baseline care plan, there was no comprehensive care plan addressing the resident's ADL functional abilities or bowel incontinence. Staff interviews confirmed the resident's high level of dependency and need for total assistance with hygiene and incontinence care, but the absence of a care plan meant that interventions such as monitoring for skin breakdown and repositioning were not formally documented or communicated to staff. The facility's policy required that a comprehensive care plan be developed within seven days of completing the MDS assessment, incorporating all goals and interventions from the baseline care plan and updating as needed based on the resident's assessed needs. In both cases, the lack of a comprehensive care plan was acknowledged by nursing leadership and staff, who stated that this omission could hinder staff's ability to provide appropriate and individualized care.
Failure to Revise Dental Care Plan After Change in Resident's Dental Status
Penalty
Summary
The facility failed to review and revise the dental care plan for one resident after the completion of the Minimum Data Set (MDS) assessment and following a change in the resident's dental status. The resident, who had diagnoses including hemiplegia, hemiparesis, dysphagia following a stroke, and major depressive disorder, was dependent on staff for oral hygiene and had no natural teeth. The care plan, dated several months prior, indicated the resident had a broken upper denture and included an intervention for the resident to refrain from using the upper denture until it was fixed. Subsequent documentation showed that the resident's upper denture was repaired and delivered, and later evaluations confirmed the resident had both upper and lower dental appliances. Interviews with staff confirmed that the resident wore both dentures daily and that staff assisted with their care. However, a review of the medical chart with the Director of Nursing revealed that the care plan had not been updated to reflect the repaired denture and the resident's current dental status, despite facility policy requiring care plan revisions after assessments and changes in condition.
Failure to Apply Geri Sleeves as Ordered
Penalty
Summary
A deficiency occurred when staff failed to apply Geri sleeves to a resident as ordered by the physician. The resident, who had diagnoses including acute respiratory failure, muscle weakness, and dementia, was assessed as having moderately impaired cognitive skills and required assistance with daily activities. The resident had a history of scratching his forearms, resulting in skin tears, and had a physician's order for the application of bilateral upper extremity Geri sleeves at all times, except during hygiene care. The care plan also specified measures to prevent further skin tears and instructed staff to follow the physician's order. During an observation, the resident was found in bed without Geri sleeves on either forearm, and the assigned LVN was unable to locate the sleeves in the resident's room. The LVN confirmed that the resident should have been wearing the sleeves per the physician's order. The DON also confirmed the order and stated that it should be followed, noting the resident's fragile skin and tendency to scratch. The facility's policy required treatments to be administered as prescribed, but the Geri sleeves were not applied as ordered at the time of the surveyor's observation.
Inaccurate Documentation of Blood Pressure Site for Resident with AV Shunt
Penalty
Summary
The facility failed to accurately document the site of blood pressure measurement for one resident with end stage renal disease who required hemodialysis via an arteriovenous (AV) shunt in the left arm. Review of the resident's medical records showed that a licensed vocational nurse (LVN) documented blood pressure checks as being performed on the left arm on multiple occasions, despite the resident's order summary indicating that no blood pressure checks or blood draws should be performed on the left arm due to the presence of the AV shunt. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for varying levels of assistance with daily activities. During interviews, the LVN acknowledged making documentation errors regarding the site of blood pressure measurement and stated that she should have reviewed her documentation for accuracy. The resident confirmed that blood pressure was only taken on the right arm, never on the left. The Director of Nursing emphasized the importance of accurate and complete documentation to ensure proper monitoring and avoid assumptions. The facility's policy required that medical record entries be complete, legible, descriptive, and accurate, and outlined the procedure for correcting errors.
Call Light Not Within Reach for Resident Requiring Assistance
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a call light was within reach for a resident as required by the care plan and facility policy. The resident, who had diagnoses including metabolic encephalopathy, COPD, and cerebral infarction, was assessed as having moderately impaired cognitive skills and required supervision or assistance for activities such as toileting, bathing, personal hygiene, and transfers. The care plan specifically indicated that the call light should be within reach due to the resident's risk for falls related to impulsive behavior and poor safety judgment. During an observation, the call light was found on the floor, out of the resident's reach, while the resident was lying in bed. Staff confirmed that the call light should have been placed on the bed next to the resident. The DON also stated that call lights should be within reach to ensure residents can call for assistance. Facility policy required call cords to be placed within the resident's reach, but this was not followed in this instance.
Failure to Maintain Sanitary Linen Management in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and sanitary environment for one of three sampled residents by not ensuring that the linen bin in a resident's room was properly managed. Specifically, the linen bin in Room A was observed to be overflowing with used white linen and was not lined with plastic, as required. The bin was also left open, contrary to facility policy and infection control standards. Both the Director of Nursing and the Registered Nurse Supervisor confirmed during interviews that the linen bin should have been lined with plastic, kept closed, and not allowed to overflow to maintain cleanliness and prevent the spread of bacteria. The resident involved had a history of falling, adult failure to thrive, was bed-confined, and had severely impaired cognitive skills, making them particularly vulnerable. The facility's policy and procedure on resident room environment emphasized the importance of providing a safe, clean, and homelike atmosphere, with attention to cleanliness and order. The failure to properly manage the linen bin in the resident's room resulted in an unsanitary environment, as directly observed and confirmed by staff.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that four of its resident bedrooms (rooms 24, 26, 28, and 44) met the minimum required size of 80 square feet per resident in multiple occupancy rooms. Measurements showed that each of these rooms, which housed three residents each, was below the required square footage per resident. The deficiency was identified through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the rooms did not meet the regulatory size requirement. Despite the deficiency, observations indicated that residents in these rooms were able to maneuver their wheelchairs and ambulate without difficulty, and nursing staff reported having sufficient space to provide care, maintain privacy, and uphold residents' dignity. Interviews with residents revealed no concerns about room size, and staff confirmed that care could be provided effectively. The facility had submitted a room waiver, and the department recommended approval of this waiver based on the findings.
Failure to Document IV Antibiotic Administration
Penalty
Summary
The facility failed to document the administration of two doses of intravenous antibiotics for a resident, as required by the Medication Administration policy. The resident, who was admitted with pneumonia, had a physician's order for cefepime HCL to be administered twice daily. However, the Medication Administration Record (MAR) lacked signatures for the 9 PM doses on two consecutive days. This omission was confirmed during interviews with two registered nurses who administered the medication but did not document it in the MAR. The Director of Nursing confirmed that the facility's policy requires licensed nurses to document the administration of medications to ensure accurate tracking. The policy mandates that nurses chart the drug, time administered, and initial their name with each medication administration. The failure to document the administration of the IV antibiotics could potentially lead to medication errors, such as double dosing, as there was no proof of administration recorded in the MAR.
Failure to Provide Appropriate Communication Boards
Penalty
Summary
The facility failed to provide appropriate communication boards for two residents, which were necessary for effective communication due to their language barriers. Resident 1, who was moderately impaired cognitively and required assistance with various activities of daily living, had a communication board that was not in her primary language and was not within her reach. This was confirmed through observations and interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, who acknowledged the communication board's incorrect language and its inaccessibility. Resident 2, who had severe cognitive impairment and required substantial assistance with daily activities, did not have a communication board available in her room. Observations and interviews with staff revealed that communication with Resident 2 was attempted through hand gestures and pointing, but the absence of a communication board hindered effective communication. The Director of Staff Development confirmed that the purpose of the communication board was to facilitate communication for residents who do not speak English, and its absence could delay care. The facility's policy on accommodating residents' communication needs, which includes providing adaptive devices like communication boards, was not adhered to in these cases. The policy mandates that such accommodations be reflected in the residents' care plans, but this was not implemented for Residents 1 and 2, leading to potential miscommunication and unmet needs.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the State Survey Agency, the state ombudsman, and local law enforcement. This incident involved a resident who was moderately impaired with cognitive skills and required assistance with daily activities. The resident had a skin discoloration on the back of their right hand, which was initially attributed to a blood draw. However, the resident later accused a Certified Nursing Assistant (CNA) of causing harm. On the morning of the incident, a Licensed Vocational Nurse (LVN) observed the discoloration and was informed by the resident of the alleged abuse. The LVN communicated this to the Director of Nursing (DON) via text message, but the DON misread the message and did not report the allegation immediately. The DON later acknowledged the oversight and reported the incident to the California Department of Public Health (CDPH) later that day. Interviews with staff revealed that the facility's policy required abuse allegations to be reported within two hours to ensure timely investigation and resident safety. The delay in reporting the incident potentially compromised the resident's protection and emotional wellbeing. The facility's policy and procedure on abuse prevention and management emphasized the importance of prompt reporting and thorough investigation of such allegations.
Failure to Provide a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as observed during a survey. Resident 19's room had peeling paint and baseboards that were peeling off the wall. Resident 19 was admitted with severe cognitive impairments and required substantial assistance with daily activities. The Director of Nursing (DON) acknowledged that the room conditions were not homelike and that the Maintenance Department was responsible for repairs, but it was unclear if these issues had been addressed during rounds. Resident 81's room also had peeling paint and white patches on the wall next to the bed and around the electrical outlet. Resident 81, who was severely impaired with cognitive skills due to dementia, required various levels of assistance with daily activities. The DON confirmed that the room conditions were not homelike and that the Maintenance Department should have addressed these issues. The Maintenance Assistant (MA 1) stated that the Maintenance Supervisor was responsible for identifying and fixing such issues but was unsure how long the problems had existed. In Resident 20's room, a plastic cup of frozen beverage belonging to staff was left on top of the resident's hand sanitizer dispenser. Resident 20, who had moderate cognitive impairments and required substantial assistance with daily activities, was affected by this unsanitary practice. The DON confirmed that staff should not leave their belongings in residents' rooms as it is not homelike and violates the residents' private space. The facility's policies emphasized the importance of maintaining a safe, clean, and homelike environment for residents, which was not upheld in these instances.
Failure to Follow Oxygen Administration Policy
Penalty
Summary
The facility failed to follow its policy to ensure licensed nurses administer oxygen to two residents, leading to potential risks in their respiratory care. Resident 143, who has dementia and chronic kidney disease, was observed having their nasal cannula tubing picked up from the floor and connected to the oxygen concentrator by a CNA, who admitted not knowing the correct oxygen dosage. This task should have been performed by a licensed nurse as per the resident's care plan and physician orders, which specified oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92% for chronic respiratory failure with hypoxia. Similarly, Resident 85, diagnosed with COPD and dependent on supplemental oxygen, was observed having their nasal cannula tubing placed and oxygen concentrator regulated by another CNA. The CNA acknowledged that this responsibility should have been handled by a licensed nurse. The resident's care plan and physician orders indicated oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or to keep oxygen saturation above 91%. Interviews with the Director of Staff Development, Infection Preventionist Nurse, and Director of Nursing confirmed that it is the responsibility of licensed nurses, not CNAs, to administer and regulate oxygen therapy. The facility's policies on oxygen therapy and oxygen safety and handling also stipulated that licensed nursing staff should administer oxygen as prescribed, ensuring safe and sanitary conditions to meet residents' needs.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were done under sanitary conditions. Specifically, a red fruit Jello container, apple sauce tray cups, rice noodles, and a garlic bag were not labeled with use by or expiration dates. Additionally, an expired cilantro bag was found mixed with carrots in the same container, and a container labeled as chorizo actually contained bacon. These deficiencies were confirmed through observations and interviews with the Dietary Staff Supervisor (DSS) and Dietary Aid (DA). The DSS acknowledged that the red fruit Jello was not labeled and should have been discarded the previous day. Similarly, the DSS confirmed the spoiled cilantro mixed with carrots and the mislabeled chorizo container containing bacon. The facility's policies and procedures, which were reviewed and revised, indicated that food items should be stored, thawed, and prepared in accordance with good sanitary practices, with all items correctly labeled and dated. However, these policies were not followed, as evidenced by the observations and interviews conducted. The DSS admitted that the cilantro should have been discarded the previous day and that the labeling errors were likely due to oversight by the cook. These practices have the potential to expose residents to pathogens and increase the risk of foodborne illnesses.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced dignity and respect for two residents. Resident 11, who has dementia and dysphagia, was observed being fed by a CNA who was standing, causing the resident to extend his neck to look up. The CNA acknowledged the mistake and stated that she should have sat down to be at the resident's eye level. The Director of Nursing confirmed that staff should sit while feeding residents to maintain dignity. Facility policies also support this practice to promote quality of life and respect for residents. Similarly, Resident 37, who has severe cognitive impairment and dysphagia, was also fed by a CNA who was standing. The CNA admitted that it was not appropriate and that sitting at the resident's eye level is important for maintaining dignity and respect. The Director of Staff Development reiterated that feeding residents while standing is not acceptable as it can make residents feel rushed and disrespected. Facility policies emphasize treating residents with kindness, respect, and dignity, and maintaining eye level during feeding is part of these guidelines.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs of three residents by not ensuring their call lights were within reach. Resident 37, who was severely cognitively impaired and dependent on assistance for daily activities, had their call light placed out of reach. This was confirmed during an observation and interview with a CNA, who acknowledged the issue. The Director of Staff Development also confirmed that the call light should always be within reach to ensure residents can call for assistance in emergencies. Resident 73, who had dementia and impaired vision, was found without their call light within reach. During an observation, the resident stated they did not know where the call light was, and a CNA later found it behind the bed. The resident's care plan indicated the need for the call light to be within reach due to their risk of falls and need for prompt assistance. Resident 3, who had Alzheimer's disease and was severely impaired in cognitive skills, was found with their call light on the floor and out of reach. An Infection Control Nurse confirmed that the call light should be next to the resident. Interviews with a CNA and the Director of Nursing highlighted the importance of having the call light within reach to prevent falls and ensure timely assistance. The facility's policy also stated that call cords should be placed within the resident's reach.
Failure to Maintain Privacy and Confidentiality of Resident Medical Records
Penalty
Summary
The nursing staff failed to provide privacy and confidentiality of Resident 11's medical records by leaving the computer screen unattended multiple times. Resident 11, who has dementia and lacks the capacity to make decisions, had their care plan information left visible on the computer screen at the nursing station. This occurred on several occasions, with the responsible nurse walking away from the station without closing the screen, leaving the resident's sensitive information exposed to passersby. The Director of Nursing (DON) acknowledged that this practice was not compliant with HIPAA regulations and emphasized the importance of closing the screen to protect patient information. Additionally, during a record review, the responsible nurse logged into the computer and left it open for another staff member to use without logging out. This second staff member also left the computer screen open with wound care and medical orders information visible. Multiple staff members walked by the nursing station while the screen was left open, further compromising the confidentiality of the resident's medical records. Both the Administrator and the DON confirmed that staff should log off and close computer screens before leaving the nursing station to ensure compliance with privacy policies.
Failure to Ensure RN Certification of MDS and CAA
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS) and Care Area Assessment (CAA) for Resident 84, as required by the facility's policy. Resident 84, who was admitted with a diagnosis of type 2 diabetes mellitus, had moderate cognitive impairment and required varying levels of assistance with daily activities. The MDS, dated 11/16/23, was signed by a Licensed Vocational Nurse (LVN) instead of an RN, which was confirmed by the Clinical Consultant during an interview and record review on 4/12/24. The facility's policy and the CMS RAI version 3.0 Manual both mandate that an RN must sign and certify the completion of the MDS and CAA sections. The Clinical Consultant verified that the LVN's signature on the MDS assessment was not in compliance with the facility's policy, which requires an RN to validate the completion of these assessments. This deficiency had the potential to result in an incomplete assessment and an inaccurate depiction of resident-specific issues, which could affect the development of an individualized care plan for Resident 84. The facility's policy, dated October 4, 2016, and the CMS RAI version 3.0 Manual, dated October 2023, both emphasize the necessity of an RN's certification for the accuracy and completeness of resident assessments and care planning.
Failure to Implement Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to implement the care plan for Resident 18, who was on oxygen therapy due to respiratory failure, COVID-19, and pneumonia. Despite the care plan specifying that the head of the bed (HOB) should be elevated to facilitate ventilation, Resident 18 was observed lying flat on her back with the HOB in a flat position. This observation was confirmed by Licensed Vocational Nurse 3 (LVN 3), who acknowledged that the HOB should be elevated to allow the lungs to expand and take in more air. LVN 3 also noted that failing to elevate the HOB could lead to shortness of breath, decreased oxygen levels, and tachycardia, potentially resulting in hospitalization for Resident 18. The Director of Nursing (DON) reiterated the importance of following the care plan to prevent respiratory distress and hospitalization, emphasizing that the care plan interventions are assessed and evaluated to meet Resident 18's specific needs. Resident 18's medical history indicated severe cognitive impairment due to dementia, making her dependent on staff for daily activities and decision-making. The facility's policies on oxygen therapy and comprehensive person-centered care planning were reviewed, both of which stress the importance of administering oxygen as prescribed and following individualized care plans. Despite these policies, the facility did not adhere to the care plan for Resident 18, leading to a deficiency that could have serious health implications for the resident.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that Resident 17, who was unable to perform activities of daily living (ADL) due to severe cognitive impairment and dependency, received the necessary services to maintain good personal hygiene. Resident 17, diagnosed with dementia and receiving palliative care, was observed with white crust on the eyelids and brownish stains around the mouth. The resident's care plan indicated a dependency on staff for personal hygiene and oral care, yet these needs were not adequately met, as evidenced by the physical condition observed during the survey. Certified Nursing Assistant (CNA) 9 acknowledged that it was not acceptable for the resident to be in such a state and that staff should ensure proper hygiene. The Director of Staff Development (DSD) also confirmed that the resident should have been cleaned immediately and any changes in the resident's condition should be reported to the charge nurse. The facility's policies on bed baths and resident rights emphasize the importance of maintaining residents' hygiene and treating them with dignity and respect, which were not adhered to in this case.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate treatment and care according to the physician's order and care plan. Resident 3, who has Alzheimer's Disease and severe cognitive impairment, was observed without an abdominal binder, which is crucial for preventing the dislodgement of her gastrostomy tube (g-tube). The binder was being washed, and no replacement was available. Staff, including the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS), acknowledged the importance of the binder and the potential risks of not having it on, but no immediate action was taken to provide a replacement binder for Resident 3. The facility also failed to reassess and monitor Resident 30's right big toe as indicated in the care plan. Resident 30, who has type 2 diabetes mellitus and moderate cognitive impairment, was observed with redness on the right big toe, which was not documented or treated. The Treatment Nurse (TN) confirmed the redness and stated that daily skin checks by Certified Nursing Assistants (CNAs) were essential for early detection and treatment of skin abnormalities. However, the redness was not reported or addressed in a timely manner, as confirmed by interviews with the CNA and LVN. Both deficiencies highlight a failure to follow physician orders and care plans, which are critical for the residents' health and well-being. The lack of adherence to these protocols had the potential to result in significant health complications for both residents, including the risk of g-tube dislodgement for Resident 3 and the worsening of a diabetic foot ulcer for Resident 30.
Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident receiving hospice services. Specifically, the facility did not maintain hospice nursing and visitation notes in the resident's medical record as required by the hospice policy. This deficiency was identified during an interview and record review, where it was found that the last Licensed Vocational Nurse (LVN) note in the hospice binder was from 2/13/24, and the last Certified Home Health Aide (CHHA) note was from 3/8/24. The Director of Nursing (DON) confirmed that all hospice notes should be in the resident's hospice binder to communicate the type of care provided, but was unsure who was responsible for ensuring this documentation was complete. The resident involved, identified as Resident 79, was admitted to the facility with diagnoses including Alzheimer's disease, iron deficiency anemia, and chronic kidney disease. The resident was severely impaired with cognitive skills for daily decision-making and was dependent on assistance for various activities of daily living. The resident had a physician order to be admitted to hospice care with specific visit frequencies for different hospice staff. However, the facility's failure to maintain up-to-date hospice notes in the resident's medical record could result in a delay or lack of coordination in the delivery of hospice care and services to the resident.
Infection Control Deficiencies
Penalty
Summary
The facility failed to enforce its infection control policies and procedures, leading to several deficiencies. Certified Nursing Assistant (CNA) 6 did not perform hand hygiene after removing dirty gloves and before putting on clean gloves during resident care. This lapse was observed during peri-care for a resident who was severely impaired with cognitive skills and dependent on assistance for daily activities. CNA 6 acknowledged the failure to perform hand hygiene, which is crucial to prevent the spread of germs and bacteria. Another deficiency involved CNA 7, who picked up a resident's nasal cannula tubing from the floor and connected it to the oxygen concentrator without replacing it. The resident, who had dementia and chronic kidney disease, required oxygen therapy to maintain adequate oxygen saturation levels. Both the Director of Staff Development (DSD) and the Infection Preventionist Nurse (IPN) confirmed that the tubing should have been changed to prevent infection. Additionally, the facility failed to disinfect laundry washers after each use. Laundry Staff (LS) 1 was observed loading dirty linen into a washer and then proceeding to the dirty linen area without performing hand hygiene after removing gloves. LS 1 also did not disinfect the washer after use, which could lead to contamination. The IPN confirmed that hand hygiene and disinfecting the washers after each use are necessary to prevent the spread of infection. These practices were not followed, as per the facility's policies on hand hygiene and infection control.
Failure to Maintain Kitchen Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when the kitchen burners did not ignite properly. During an initial tour, it was observed that the cook used a piece of paper to ignite the burner, stating that this method made the flame bigger. The cook admitted to having burned himself before while using this method and mentioned that the igniter was often borrowed by staff and not returned. The Dietary Staff Supervisor (DSS) acknowledged the danger of using paper to ignite the burners and stated that the cook should use an igniter, which was currently misplaced. The DSS also mentioned that maintenance is scheduled monthly or as needed to repair or replace kitchen equipment, and she would contact the maintenance supervisor immediately to address the issue. The Maintenance Assistant (MA) was interviewed the following day and stated that he was not aware of the issue with the kitchen burners. A review of the facility's policies and procedures indicated that the maintenance department is responsible for ensuring that all equipment is maintained in a safe and operable manner. The policies also outlined that the Director of Maintenance is responsible for developing a maintenance schedule to ensure safety. Despite these policies, the failure to maintain the kitchen burners in safe working condition was evident, posing a risk to staff safety.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that four of its resident bedrooms met the federal regulation requirement of at least 80 square feet per resident in multiple resident bedrooms. Specifically, Rooms 24, 26, 28, and 44 were found to be below the required space per resident. Room 24 measured 230.84 square feet and housed three residents, Room 26 measured 221.56 square feet and housed three residents, Room 28 measured 217.74 square feet and housed three residents, and Room 44 measured 237.6 square feet and housed three residents. These measurements were confirmed during a general observation of the facility and through a review of the Client Accommodation Analysis record by the Administrator, who acknowledged that these rooms did not meet the 80 square feet per resident requirement. Despite the space constraints, the facility had submitted a room waiver request, indicating that there was adequate space for nursing care and that the health and safety of the residents were not in jeopardy. The waiver request, dated 4/9/24, sought re-authorization for the four resident rooms with floor areas ranging from 215 to 235 square feet. The Department recommended the room waiver for Rooms 24, 26, 28, and 44 as requested by the facility.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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