Keystone Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 3672 North First Street, Fresno, California 93726
- CMS Provider Number
- 056266
- Inspections on file
- 26
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Keystone Post-acute during CMS and state inspections, most recent first.
A resident with complex medical conditions, including CKD on dialysis, anemia, diabetes, psychiatric disorders, and chronic leg ulcers, was admitted after hospital care and determined by the ADM, DON, and admissions staff to be appropriate for the facility’s services. The resident was later sent to the hospital for a critically low Hgb level and stabilized, and the hospital attempted to return the resident the next day, within the facility’s seven-day bed-hold period. Despite policies requiring residents to be permitted to return within the bed-hold period and requiring facility-initiated discharges after emergency transfers to be based on the resident’s status at the time of return, the ADM informed hospital case management that the facility did not want the resident back due to aggressive behaviors. Staff reported that the resident’s room was reassigned to other residents while the bed-hold period was still in effect, and facility leadership acknowledged that no follow-up was made with the hospital to ensure appropriate placement, resulting in the resident not being readmitted.
Surveyors found that the kitchen's three-compartment sink, used for both dishwashing and food preparation, lacked required air gaps to prevent backflow of sewage water. Staff confirmed the sink was used for thawing meats and draining canned fruit while dirty dishes were present, and the Maintenance Director stated no air gaps were present in any kitchen sinks. Facility policies and the FDA Food Code require air gaps to prevent cross-contamination and foodborne illness.
The facility failed to document received by dates for three controlled medications for one resident and four for another in the controlled drug disposition log. The DON and pharmacist confirmed that facility policy requires this documentation to ensure timely and accurate disposal, but the process was not followed, resulting in incomplete records for these controlled substances.
Three residents with diabetes and cognitive impairments did not receive their prescribed insulin before meals as ordered, due to delays in blood sugar checks and medication administration by nursing staff. Insulin was given after meals had started or finished, contrary to physician orders and manufacturer recommendations, as confirmed by staff interviews and record reviews.
Surveyors found that medications, including inhalers, eye drops, and a controlled substance, were stored in the medication room and carts without proper pharmacy or resident labels. Staff and pharmacy confirmed that all medications should be labeled to ensure correct administration, but this process was not followed for several residents' medications, contrary to facility policy.
Two residents did not receive scheduled showers over several weeks, with documentation confirming multiple missed opportunities for personal hygiene care. Both residents expressed feeling dirty and neglected, and staff interviews revealed that showers were not properly documented or escalated. Facility leadership confirmed expectations for shower provision and documentation, but records showed a lack of follow-through and absence of care plan updates.
A resident with moderate cognitive impairment was admitted with the facility administrator assigned as decision maker, but the facility did not attempt to contact the resident's family or friends to act as a representative. Multiple informed consents for treatment and interventions were signed solely by the administrator without involving the resident, a family friend, or a patient representative, and there was no documentation of required interdisciplinary team meetings or consultation with appropriate representatives.
A resident with moderate cognitive impairment and multiple medical conditions was provided with an over-the-bed table that had a large chip, exposing sharp edges and a porous surface. Staff and clinical leaders confirmed the table posed risks for skin tears and infection, and that it remained in use for an extended period despite facility policies requiring prompt repair or removal of hazardous furniture.
A resident with a newly placed central venous catheter port and surgical incision did not have a comprehensive, individualized care plan addressing monitoring and care for these conditions. Staff did not change the resident's dressing or use appropriate infection control precautions, and there was no EBP signage. The absence of a care plan was confirmed by the Infection Preventionist and Director of Nursing, and staff relied on verbal reports rather than documented care plans.
A resident with severe cognitive impairment and a history of urinary retention did not have his urinary catheter changed as ordered by the physician, and staff failed to notify the physician of abnormal findings such as dark, foul-smelling urine with sediment and mucus. The physician's order was not entered as a scheduled task, leading to the missed catheter change and lack of timely intervention for possible infection.
A resident with cognitive impairment and no family involvement had multiple informed consents for treatment and interventions signed by the administrator, who was not related to or familiar with the resident, without documented consultation with the resident, a family friend, or the interdisciplinary team. Despite facility policies and state requirements for IDT involvement and inclusion of a patient representative, these steps were not followed, resulting in a failure to ensure the resident's wishes and preferences were considered in care planning.
Two residents were not provided appropriate infection prevention measures: one with a central venous catheter port was not placed on Enhanced Barrier Precautions, and another with an indwelling urinary catheter had visible signs of infection and did not receive timely catheter care as ordered. Staff did not follow established protocols for PPE use, documentation, or escalation of abnormal findings to the physician.
A resident with severe cognitive impairment and multiple medical conditions was found without access to a call light, as it was strung over the head of the bed and tucked between the mattress and bed frame. Staff interviews confirmed the call light was not accessible and that this did not follow facility policy or training, which require call lights to be within reach for all residents.
A resident with moderate cognitive impairment and a history of epilepsy eloped from the facility unsupervised. Despite a Code GREEN being initiated and a search conducted, the resident was not located until they returned to their apartment days later. The facility's policy for missing residents was followed, but the resident's recent admission and cognitive status may have contributed to the incident.
Two residents involved in a verbal altercation did not have their care plans updated to include new interventions decided by the IDT, such as daily visits from the SSD and AD. These visits were not consistently conducted, leaving the residents at risk of not receiving appropriate care. Interviews with staff confirmed the oversight in updating care plans and executing the planned interventions.
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation and care planning. A resident's 15-minute checks were not documented for a period following an incident, another resident's care plan contained goals for a different resident, and a third resident's safety checks were missing for two days after an altercation. These lapses violated the facility's documentation policy.
An unknown visitor entered a long-term care facility on two occasions, entering multiple resident rooms and stealing a phone from a resident. This incident caused fear among residents, highlighting a failure in ensuring a safe environment. Staff recounted the visitor's movements, and police were called, but no arrest was made.
The facility failed to maintain appropriate temperatures in the kitchen's large pantry storage room, with temperatures reaching up to 96 degrees Fahrenheit. This was confirmed by both a temperature gun and a wall thermometer. The Dietary Coordinator and LVN acknowledged the risk of food spoilage and potential food-borne illness due to the inappropriate storage conditions. The Dietary Supervisor confirmed that the temperatures had been consistently high, posing a risk to residents' health.
The facility failed to ensure that 16 residents were properly assessed for the risk of entrapment from bed rails before their installation. The residents did not have bed rail risk assessments, consents, physician orders, or care plans in place prior to the use of the bed rails. Staff acknowledged that the facility did not follow the proper procedures, and the facility's policies and procedures were not adhered to, potentially causing serious harm to the residents.
The facility failed to ensure a full-time DON from 3/13/24 to 4/16/24, resulting in a lack of guidance and leadership for nursing staff and potentially impacting resident care.
The facility failed to ensure that ten residents were free from unnecessary psychotropic medications by not implementing adequate behavior and side effect monitoring, and not providing resident-specific non-pharmacological interventions. This led to potential risks such as medical interactions and adverse reactions.
The facility failed to ensure food and ice were stored in accordance with professional standards for food service safety. The ice machine was not sanitized according to the manufacturer's directions, and the dishwashing machine did not reach the required temperature for the rinse cycle. These failures had the potential to result in the growth of microorganisms, posing a risk of foodborne illnesses for the 63 residents eating and drinking in the facility.
The facility failed to obtain informed consents for psychotropic medications for four residents. Medications were administered without complete consent forms, missing signatures from residents or their representatives and physicians. The facility's policy requiring informed consent was not followed.
The facility failed to provide a homelike environment for several residents, with issues such as mold, peeling paint, exposed flooring, and low water pressure observed in various rooms and bathrooms. Staff confirmed that these conditions were not acceptable and could lead to potential health risks.
The facility failed to develop and implement comprehensive care plans for four residents, including addressing severe weight loss, dental needs, and oxygen therapy. This led to unmet care needs and the use of oxygen without physician orders.
The facility failed to follow professional standards for oxygen therapy, administering it without physician orders to two residents and not properly labeling and storing oxygen tubing for three residents. This resulted in unnecessary treatments and potential infection risks.
The facility failed to ensure staff competency and training, as evidenced by incomplete blood glucometer competency for an LVN, missing mandatory annual competency trainings for several LVNs and CNAs, and lack of initial skills check-off for a CNA. This placed residents at risk for care not provided in a safe and competent manner.
The facility failed to ensure complete and accurate documentation of POLST forms for two residents, potentially affecting their end-of-life care wishes. Both residents were cognitively intact, but their POLST forms were missing critical information, as confirmed by the Medical Records Director and Interim Director of Nursing.
The facility failed to maintain a sanitary environment, with issues including a resident's oxygen cannula on the floor, soiled oxygen concentrators, a damaged nurses' station countertop, lack of Legionella testing, and dirty medication carts and pill crushers. Staff interviews confirmed these items should be cleaned regularly to prevent contamination and infection.
The facility failed to implement and maintain an effective training program for LNs, CNAs, and ancillary support staff, resulting in incomplete and outdated training records in critical areas such as abuse, dementia, communication, resident rights, infection control, and falls. This deficiency was acknowledged by the DSD and IDON, who admitted that required training and competencies were not completed on time, potentially placing residents at risk.
The facility failed to timely address a resident's severe unplanned weight loss of 22 pounds over 41 days. The nutritional assessment and care plan were delayed, and the only intervention was a house supplement and lab work ordered on 4/5/24. The DON confirmed that the nutritional assessment and care plan were completed late, which was not acceptable practice.
The facility failed to ensure that a resident was offered or administered the pneumonia vaccine. The resident's EMR showed no records of the vaccine being given or refused since admission, and the resident had moderate cognitive impairment. The facility's policy requires consents for immunizations to be signed by the resident or their responsible party.
The facility failed to maintain the kitchen flooring and a shared bathroom ceiling, leading to potential health risks for residents. The kitchen had multiple sections of missing epoxy flooring, resulting in a buildup of food particles and debris. In a shared bathroom, the ceiling had blackened areas and a hole, suspected to be mold due to an HVAC leak. The Environmental Services Director acknowledged the issues but had not completed the necessary repairs.
The facility failed to ensure that the handrail in one of three hallways was firmly secured to the wall, posing a potential risk of injury to residents, visitors, and staff. Observations and interviews with staff confirmed that the handrail was loose and not safe for residents to use. The facility's policy and professional standards require handrails to be firmly secured, which was not adhered to in this case.
Failure to Readmit Hospitalized Resident Within Bed-Hold Period Due to Behavioral Concerns
Penalty
Summary
The deficiency involves the facility’s failure to readmit a hospitalized resident within the facility’s bed-hold period despite the resident continuing to require the skilled services the facility was capable of providing. The resident had been admitted from an acute care hospital with multiple complex diagnoses, including muscle wasting and atrophy, muscle weakness, type 2 diabetes, bipolar disorder, schizophrenia, chronic kidney disease with dependence on dialysis, nephrotic syndrome, anemia, hypertensive heart disease, and acute kidney failure. Staff, including CNAs and LVNs, consistently described the resident as medically fragile, with significant needs for wound care to bilateral lower leg ulcers, regular wound treatments, multiple medications, dialysis, and frequent therapy to address muscle wasting. The facility’s own admission criteria policy stated that it only admits residents whose medical and nursing needs can be met, and the Admissions Director, DON, and Administrator all agreed at admission that the facility was well suited to meet this resident’s needs. The resident was transferred to the hospital on the order of the physician after a critically low hemoglobin level of 4.6 was reported following dialysis. Staff interviews and record review showed that this transfer was for a medical issue related to low hemoglobin, not for behavioral reasons. The Social Services Director and Admissions Director stated that the hospital stabilized the resident and attempted to return him to the facility the next day, within the facility’s seven-day bed-hold period. The facility’s Bed-Holds and Returns policy indicated that residents who seek to return within the bed-hold period must be permitted to return, regardless of payer source, and allowed to return to their previous room if available. The Transfer or Discharge, Facility-Initiated policy further specified that if discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge must be based on the resident’s status at the time the resident seeks to return. Despite these policies and the resident’s ongoing need for skilled care, the Administrator communicated to the hospital case management department that the facility did not want the resident to return, citing his aggressive behaviors. Staff interviews revealed that the resident’s room was reassigned to other residents within days of his transfer, even though he remained within the seven-day bed-hold period and had been sent out for a medical issue. Multiple staff members, including CNAs and the restorative nurse assistant, observed that the resident’s room was already occupied and expressed that they did not think he would be returning. The Admissions Director and Administrator acknowledged that the facility did not follow up with the hospital after refusing readmission, and the Admissions Director stated that the facility should have ensured the resident found proper placement. As a result of these actions and inactions, the resident was not readmitted to the facility despite requiring the services the SNF provided and having a bed on hold under facility policy. The facility’s own leadership confirmed that the resident had been appropriately admitted initially, that his medical and financial records had been reviewed, and that the facility had accepted responsibility for his care. The DON and Administrator reiterated that the resident was sent to the hospital for a medical issue that was subsequently resolved, and that he remained within the defined bed-hold period when the hospital attempted to return him. Nonetheless, the facility refused to accept him back based on behavioral concerns that were not the reason for his hospital transfer, and did not base the discharge decision on his status at the time he sought to return, contrary to the facility’s Transfer or Discharge policy. This sequence of decisions and the reassignment of his bed led directly to the resident not being readmitted to the facility after hospitalization.
Lack of Air Gaps in Kitchen Sinks Creates Food Safety Deficiency
Penalty
Summary
The facility failed to prepare and distribute food in accordance with professional standards for food service safety by not providing air gaps in the three-compartment kitchen sink, which is necessary to prevent backflow of sewage water. Observations revealed that the three-compartment sink, used for both dishwashing and food preparation, did not have a visible air gap. Kitchen staff confirmed that the sink was used for cleaning dishes and food preparation, including thawing turkey breasts and lunch meat under running water, and draining canned fruit, all while dirty dishes were present in other compartments of the same sink. The Maintenance Director confirmed that no air gaps were present in any kitchen sinks. Interviews with staff, including the Certified Dietary Manager, acknowledged the potential for cross-contamination and foodborne illness if the sink were to back up during use. Facility policies reviewed indicated that air gaps are required to prevent backflow and that food should be thawed in a clean, sanitized food sink separate from wash sinks. The FDA Food Code was also cited, which requires air gaps to prevent direct connections between sewage systems and equipment used for food or utensil washing.
Incomplete Documentation of Controlled Medication Disposition
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents when controlled medication entries for both individuals did not include received by dates in the controlled drug disposition log. Specifically, three controlled medications for one resident and four for another were listed for disposition without the required documentation of when the medications were received by the DON from the floor nurse. The DON confirmed during interviews that the received by date was not documented for these entries, which was contrary to facility policy and procedure. Interviews with both the DON and the facility pharmacist revealed that the expected process was for the floor nurse to bring controlled medications for waste to the DON, who would then document all required information, including the received by date, in the disposition log. Both the DON and the pharmacist emphasized the importance of this documentation for ensuring timely and accurate disposal of controlled medications. The absence of received by dates meant that the facility could not verify when the medications were received or ensure they were disposed of within the required three-month timeframe. A review of facility policies confirmed that all controlled substances must be properly documented upon receipt and during disposal, including the date received, to comply with federal, state, and local regulations. The DON acknowledged that the policy was not followed in these instances, resulting in incomplete records for the controlled medications of both residents.
Failure to Administer Insulin Prior to Meals as Ordered
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors when they did not receive their prescribed insulin prior to eating their meals, as ordered by their physicians and recommended by the manufacturer. Observations revealed that a registered nurse was delayed in checking blood sugar levels and administering insulin, resulting in insulin being given after the residents had already begun or finished their meals. In one instance, a nurse was observed checking a resident's blood sugar after the meal had started, and insulin was administered during the meal. In other cases, residents had already eaten before their blood sugar was checked and insulin was administered. The residents involved had complex medical histories, including type II diabetes mellitus, cognitive impairments, and other significant health conditions such as heart failure, acute respiratory failure, hemiplegia, and amputations. Assessments indicated that two of the residents were severely cognitively impaired, while one was moderately impaired. Physician orders for all three residents specified that insulin should be administered subcutaneously before meals, and this was not followed in the observed incidents. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for blood sugar checks and insulin administration to occur prior to meals to ensure accurate dosing and effectiveness. The facility's job description for registered nurses also required medication administration in accordance with physician orders and regulatory standards. Reference materials reviewed by surveyors supported the need for insulin to be administered before meals, as deviations could result in significant health risks.
Failure to Properly Label Medications in Medication Room and Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling of medications in both the medication room and two medication carts. Specifically, an inhaler belonging to one resident was found in the medication room without a resident or pharmacy label. Additionally, multiple residents' eye drops and a controlled medication (liquid morphine sulfate) were found in medication carts without appropriate labeling. Staff interviews confirmed that all medications, including inhalers, eye drops, and controlled substances, were expected to have pharmacy or resident labels to ensure correct administration. During observations, staff members, including the DON, LVN, and RN, acknowledged that the lack of labeling could prevent accurate identification of medications, especially when multiple residents were prescribed similar drugs. The staff stated that it was the pharmacy's responsibility to provide labels, and the nursing staff were expected to notify the pharmacy if a medication was found without a label. The pharmacist in charge also confirmed that all medications should be labeled and that the process had not been followed for the medications in question. A review of facility policies indicated that all prescription drugs must be labeled and that medication administration procedures require verification of resident name, medication name, form, dose, route, and time. The DON confirmed that the facility had not adhered to its own medication labeling policies for the affected residents, resulting in the observed deficiencies.
Failure to Provide Scheduled Showers and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide scheduled showers to two residents, resulting in nine missed opportunities for personal hygiene care. One resident, who was cognitively intact and scheduled for showers twice a week, did not receive showers on multiple scheduled days and reported feeling dirty, neglected, and isolated. The resident stated she had not refused any showers and was not given a reason for the missed care. Another resident, with moderate cognitive impairment and a diagnosis of major depressive disorder, also missed several scheduled showers and expressed feeling dirty and gross due to the lack of personal hygiene care. Record reviews confirmed that both residents had missed multiple scheduled showers, with documentation either absent or marked as not applicable for those dates. There were no progress notes or care plans addressing missed or refused showers in either resident's medical record. Staff interviews revealed that showers were to be documented in both a shower binder and the electronic medical record, and that blank spaces or 'N/A' entries indicated missed showers. Staff acknowledged the importance of showers for resident assessment and dignity, and confirmed that there were no external factors, such as water or equipment issues, that would have prevented showers from being given during the relevant period. Facility leadership, including the Director of Staff Development, Infection Preventionist, and Director of Nursing, stated that it was their expectation for staff to complete and document showers as scheduled, escalate missed showers, and ensure resident rights to personal hygiene were honored. However, the lack of documentation, absence of progress notes, and failure to address missed showers in care plans demonstrated a breakdown in the facility's processes, resulting in residents not receiving the care to which they were entitled.
Failure to Involve Resident Representative in Care Decisions and Informed Consent
Penalty
Summary
The facility failed to ensure that a resident's representative was given the opportunity to exercise the resident's rights during the care process. The resident in question was admitted with diagnoses including dementia, major depressive disorder, dysphagia, and muscle weakness, and was assessed to have a moderate cognitive deficit. Despite this, the facility did not attempt to contact the resident's family or friends to act as a representative or decision maker at admission or during the care process. Instead, the facility administrator was assigned as the resident's decision maker without documented efforts to involve or consult with the resident's family friend, who had previously acted as a patient advocate and was authorized to receive medical information. Multiple informed consent forms, including those for treatment, life-sustaining treatment, side/bed rail use, and psychotherapeutic drugs, were signed solely by the administrator. There was no evidence that the resident, the family friend, or any other representative was involved in or acknowledged these consents. The medical record lacked documentation of interdisciplinary team (IDT) meetings prior to obtaining these consents, and there was no indication that the resident, family friend, or a patient representative was consulted or involved in the decision-making process for these significant medical interventions. Interviews with facility staff, including the social services director, administrator, and director of nursing, confirmed that the required process for involving a patient representative and conducting IDT meetings was not followed. Staff acknowledged that no attempts were made to contact the resident's family, friends, or listed contacts to act as a decision maker or participate in care planning. Facility policies and state guidance reviewed during the survey emphasized the importance of involving a patient representative and conducting IDT meetings for residents lacking capacity, but these procedures were not adhered to in this case.
Unsafe and Unclean Furniture Provided to Resident
Penalty
Summary
A deficiency occurred when a resident was not provided with safe, clean, and comfortable furniture in their room. The over-the-bed table used by the resident had a significant chip measuring approximately 2 inches by 1.5 inches, resulting in exposed sharp edges and a porous surface. This condition was observed multiple times over several days, and the resident reported that the damage had been present for about six months. The resident expressed a desire for a new table, indicating awareness of the issue and its duration. Staff interviews confirmed the unsafe condition of the table. A CNA acknowledged that all furniture should be free of hazards and specifically noted the risk of injury from the sharp edges and porous surface. An LVN reviewed a photo of the table and stated there was a strong possibility of skin tears and infection, emphasizing the risk of bacteria harboring in the damaged area. The Director of Staff Development, who also serves as the Infection Preventionist, confirmed that the porous area could not be cleaned effectively and posed a risk for blood or bacteria to remain, further increasing the risk of infection. The Director of Nursing reviewed the situation and stated that it is the responsibility of all staff to maintain a safe environment by ensuring equipment is clean and intact. The DON noted that the table should have been removed immediately and that staff failed to follow facility policies by not notifying the Maintenance department promptly or removing the damaged table as soon as the chip occurred. Facility policies reviewed require that patient rooms be free from hazards, that repairs be addressed promptly, and that furniture in disrepair be reported to Maintenance.
Failure to Develop and Implement Individualized Care Plan for Central Line and Surgical Wound
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, individualized care plan for a resident who had a newly placed central venous catheter port and a surgical incision wound. The resident, who had been admitted from an acute care hospital with multiple diagnoses including liver cell carcinoma, a femur fracture, cerebral ischemia, and major depressive disorder, was observed with a dressing on his right upper chest. The resident reported that nurses had not changed his dressing and that staff did not use gowns or gloves when providing care. There was also no enhanced barrier precautions (EBP) signage on the resident's door, despite the presence of a central line and surgical wound. Record review revealed that the resident's care plan did not include any interventions or monitoring instructions for the central venous catheter port or the surgical incision. The Infection Preventionist confirmed that there was no care plan for the catheter line, even though it had been placed the previous week. The Infection Preventionist stated that a care plan should have been created upon the resident's return to the facility after the procedure, and that such a plan is necessary to guide staff in monitoring for infection, identifying symptoms, and knowing when to contact a physician. Interviews with staff indicated a lack of awareness and use of care plans in daily care. Certified Nursing Assistants reported relying on verbal reports rather than reviewing care plans, and the Director of Nursing acknowledged that the absence of a care plan for the catheter line meant the resident did not have a specific, individualized plan to meet his needs. Facility job descriptions and policies reviewed also emphasized the importance of care plans in ensuring appropriate care and communication among staff, but these were not followed in this instance.
Failure to Change Urinary Catheter and Notify Physician of Abnormal Findings
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of urinary retention, hemiplegia, and cerebrovascular accident did not have his urinary catheter changed according to the physician's order. Observations revealed that the resident's catheter bag contained dark, foul-smelling urine with visible sediment and mucus, and the room had a strong odor of urine. Staff interviews confirmed that these were signs of a possible urinary tract infection (UTI) and that such findings should be reported to nursing staff for further action. Record reviews showed that the physician's order to change the catheter drainage bag on the 15th of each month and as needed was not entered as a scheduled task in the Treatment Administration Record (TAR), resulting in the catheter not being changed as ordered. Nursing staff acknowledged that the presence of sediment and foul odor in the catheter tubing should have prompted a catheter change, physician notification, and further assessment, including a urinalysis. However, these actions were not taken, and the physician was not notified of the missed catheter change or the abnormal findings. The facility's care plan and job descriptions required staff to follow physician orders, recognize abnormal findings, and escalate concerns to the physician. Professional references and guidelines reviewed by the surveyors supported the expectation that nurses follow physician orders unless there is a safety concern, and that failure to do so can be considered neglect. The lack of adherence to these standards resulted in a missed catheter change and failure to notify the physician of potential infection indicators.
Failure to Involve Appropriate Decision Makers and IDT in Resident Care Planning
Penalty
Summary
The facility failed to ensure that a resident was effectively and efficiently cared for by the administrator, who acted as the resident's decision maker. The resident, who had diagnoses including dementia, major depressive disorder, dysphagia, and muscle weakness, was admitted without family involvement but had a family friend who had previously served as a patient advocate. Despite this, the administrator signed multiple informed consent documents for the resident's care and treatment, including consent to treat, POLST, side/bed rail use, and psychotherapeutic drug administration, without documented consultation with the resident, the family friend, or an interdisciplinary team (IDT). Interviews with the family friend, social services director (SSD), administrator (ADM), and director of nursing (DON) revealed that the facility did not follow the required process for unrepresented residents. The SSD and ADM acknowledged that the California Department of Aging had provided in-service training on the IDT process for unrepresented residents, which requires the inclusion of a patient representative and IDT review for medical decisions requiring informed consent. However, there was no documentation that such meetings or consultations occurred prior to the administrator signing the consents. The family friend, who was known to the resident and had been involved in his care previously, was not contacted or included in the decision-making process, despite the resident's agreement for the friend to receive medical updates and be involved in care. Record reviews and staff interviews confirmed that the administrator was not related to the resident and did not know him prior to admission. The facility's own policies, as well as state regulations, require that the resident's wishes and preferences be considered and that appropriate representatives be involved in care planning and consent processes. The lack of documentation and involvement of the IDT, patient representative, or the resident himself in these decisions constituted a failure to uphold the resident's rights and ensure care was provided in accordance with legal and regulatory requirements.
Failure to Implement Infection Control Precautions and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents. For one resident with a central venous catheter port, staff did not implement Enhanced Barrier Precautions (EBP) as required. The resident, who had a port placed for chemotherapy, reported that nurses had not changed his dressing and staff did not use gowns or gloves during care. There was no EBP signage or PPE cart outside the resident's room, and both nursing and CNA staff confirmed that EBP should have been in place for residents with indwelling devices or wounds. The Director of Nursing also acknowledged that EBP should have been implemented upon admission for such residents. Another resident with an indwelling urinary catheter was observed to have dark, foul-smelling urine with visible mucus and sediment in the catheter tubing. The room had a strong odor of urine. Staff interviews confirmed that these were signs of a possible urinary tract infection and that such findings should be reported to a nurse. The resident's physician order required the catheter drainage bag to be changed monthly and as needed, but this order was not entered as a task in the Treatment Administration Record, and the change was not completed as ordered. Nursing staff confirmed that the catheter tubing should have been changed and that the physician should have been notified of the abnormal findings. Record reviews and staff interviews further revealed that the facility's infection preventionist and Director of Nursing expected staff to be competent in catheter care and to escalate any concerns, such as signs of infection, to the physician. The care plan for the resident with the urinary catheter also required staff to report signs and symptoms of infection and to change the catheter as ordered. However, these expectations were not met, resulting in a failure to follow infection control protocols and physician orders for both residents.
Failure to Ensure Accessible Call Light for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, dysphagia, and a lumbar fracture was found without access to a call light. During an observation, the call light cord was strung over the head of the bed and tucked between the mattress and bed frame, making it inaccessible to the resident. The resident was observed to be disheveled, unable to answer questions coherently, and unable to make eye contact. Multiple staff members, including CNAs and an LVN, confirmed during interviews that the call light was not accessible and stated that all residents, regardless of cognitive status, should have their call lights within reach. Staff acknowledged that the call light's placement could prevent the resident from calling for help in an emergency. The responsible party for the resident also stated that the call light should be within reach due to the resident's confusion and need for assistance. The Director of Nurses confirmed that the staff did not follow facility policy or in-service training regarding call light accessibility. Review of facility policy and recent in-service training minutes indicated that staff are required to ensure call lights are within reach of residents at all times. The failure to provide an accessible call light was directly observed and corroborated by staff and documentation.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain an accident-free environment for a resident who eloped from the facility. The resident, who had a history of epilepsy, cerebral ischemia, and moderate cognitive impairment, was admitted to the facility with an elopement risk assessment score that did not classify them as high risk. Despite this, the resident managed to leave the facility unsupervised and undetected through the front entrance door. On the day of the incident, the resident was observed speaking with visitors in their room. After the visitors left, the resident was no longer in their room, prompting a staff member to notify the charge nurse, who then initiated a Code GREEN. A search of the facility and surrounding areas was conducted, but the resident was not located. The local police department was notified and assisted in the search, but the resident remained missing until they returned to their apartment days later. Interviews with staff and visitors revealed that the resident assumed they would leave with the visitors, but was informed they needed to check with the facility. The facility's policy required staff to initiate a search and notify relevant parties when a resident is missing, which was followed. However, the resident's moderate cognitive impairment and recent admission may have contributed to the oversight in supervision, leading to the elopement.
Failure to Implement Comprehensive Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise and implement a comprehensive person-centered care plan for two residents involved in a verbal altercation. The Interdisciplinary Team (IDT) met and decided on interventions, including daily visits from the Social Services Director (SSD) and Activities Director (AD) for 72 hours. However, these interventions were not updated in the residents' care plans, and the visits were not consistently conducted as planned. Resident 1 and Resident 2 were involved in a verbal altercation, which prompted the IDT to suggest new interventions to monitor and address potential psychosocial distress. Despite the IDT's decision, the care plans for both residents were not updated to reflect the new interventions, and the SSD and AD did not complete the scheduled visits on all required days. This oversight left the residents at risk of not receiving the necessary care to ensure their safety and well-being. Interviews with facility staff, including the SSD, AD, and Assistant Director of Nursing (ADON), revealed that the care plans were not updated as required, and the scheduled visits were not fully executed. The facility's policies and procedures emphasize the importance of comprehensive, person-centered care plans, but these were not adhered to in this instance, leading to a deficiency in care for the residents involved.
Deficiencies in Resident Documentation and Care Planning
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and care planning. For Resident 1, the facility was unable to locate documentation for 15-minute checks that were supposed to be conducted from the afternoon of September 20 to the morning of September 21. This documentation was crucial as it was part of the interventions following a verbally aggressive incident involving Resident 1. Despite multiple attempts by staff, including the Director of Staff Development and the Assistant Director of Nursing, the records could not be found, indicating a lapse in maintaining accurate and complete records as per the facility's policy. Resident 2's care plan contained a significant error where the goals documented were mistakenly those of another resident, Resident 1. This error was identified during a review of Resident 2's mood care plan, which was supposed to address the resident's risk for altered mood and behavior. The Licensed Vocational Nurse and the Assistant Director of Nursing both acknowledged the mistake, noting that the care plan inaccurately reflected another resident's goals, which compromised the accuracy of Resident 2's medical records. For Resident 4, the facility failed to document 15-minute checks for two days following an altercation with another resident. The checks were part of the interventions to ensure Resident 4's safety after the incident. However, documentation for September 17 and 18 was missing, and the Assistant Director of Nursing confirmed the absence of these records. This lack of documentation violated the facility's policy on charting and documentation, which requires complete and accurate records of treatments and interventions.
Security Breach and Theft in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment for six residents when an unknown visitor entered the building on two occasions. On the second occasion, the visitor entered three resident rooms and stole a cellular telephone from one resident. This incident resulted in two residents experiencing fear, and one resident had their phone stolen. The visitor was initially asked to leave the night before but returned the following morning, entering multiple rooms and causing distress among the residents. The facility's staff recounted the visitor's movements, noting that he entered rooms housing two residents each. The visitor was eventually escorted out by staff, and the police were called, although no arrest was made. Interviews with residents revealed feelings of fear and insecurity, with one resident expressing a loss of safety and concern over the facility's security measures. The facility's assessment highlighted the need for recognizing uninvited visitors or suspicious behavior, which was not effectively managed in this instance.
Inadequate Food Storage Conditions in Pantry
Penalty
Summary
The facility failed to maintain safe and sanitary food storage conditions in the kitchen's large pantry storage room, where temperatures were recorded as high as 96 degrees Fahrenheit. This was observed during a survey on June 13, 2024, when both a temperature gun and a wall thermometer confirmed the elevated temperature. The Dietary Coordinator (DC) acknowledged that the temperature was inappropriate for storing dry goods, which could spoil and pose a risk of food-borne illness to residents consuming meals prepared with these ingredients. The License Vocational Nurse (LVN) also confirmed the high temperature and noted that it was not suitable for storing items like condensed milk and broth liquids, which require a cool, dry space. Further observations and interviews with the Dietary Supervisor (DS) revealed that the pantry's temperature had been consistently high, ranging from 77 to 104 degrees Fahrenheit from June 3 to June 13, 2024, as per the facility's Dry Storage Room Temperature Log Sheets. The DS confirmed that the current temperatures were not appropriate for the items stored and acknowledged the potential risk of residents getting sick due to food spoilage. The facility's policy and professional guidelines recommend storage room temperatures between 50 and 70 degrees Fahrenheit, indicating a significant deviation from the standard, which was not addressed in a timely manner by the facility management.
Failure to Properly Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that 16 residents were properly assessed for the risk of entrapment from bed rails before their installation. The residents did not have bed rail risk assessments, consents, physician orders, or care plans in place prior to the use of the bed rails. This deficiency was observed in multiple residents' rooms, where bed rails were installed without following the necessary protocols, including obtaining informed consent and conducting risk assessments. For instance, Resident 6 had a bed assist rail without a risk assessment, consent, or care plan, and similar issues were found with Residents 8, 27, and 38, among others. During interviews, staff members, including the Licensed Vocational Nurse (LVN) and the Interim Director of Nurses (IDON), acknowledged that the facility did not follow the proper procedures for bed rail installation. The LVN stated that bed rails could be considered restraints and that consents were necessary to prevent potential injuries. The IDON confirmed that there was no documentation of bed rails being installed according to the manufacturer's recommendations, and assessments, consents, and orders were not completed prior to the use of bed rails. The facility's policies and procedures were reviewed and indicated that bed rails should not be used unless specific criteria were met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these protocols were not followed, as evidenced by the lack of documentation and incomplete assessments and consents. The failure to adhere to these procedures had the potential to cause serious harm, injury, or death to the residents involved.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a registered nurse was designated as the Director of Nursing (DON) on a full-time basis from 3/13/24 to 4/16/24. During this period, the DON was on medical leave, and the facility did not have a designated full-time DON. The Interim DON (IDON) was initially hired as the Minimum Data Set (MDS) Coordinator and only started filling in as an on-call IDON on 3/18/24. The IDON was not available full-time until 4/16/24. This gap in leadership resulted in a lack of guidance, direction, and leadership for the nursing staff, potentially impacting the quality of care and services provided to the residents. Interviews with the Administrator (ADM) and the IDON revealed that during the DON's leave of absence, the IDON was only available on an on-call basis, and nurses had to reach him by phone if needed. The facility's job description for the DON emphasized the importance of the role in ensuring the highest quality of resident care, supporting staff, and coordinating nursing services. The absence of a full-time DON during the specified period meant that these critical responsibilities were not adequately fulfilled, leading to potential negative impacts on the residents' care and treatment.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that ten residents were free from unnecessary psychotropic medications. Specifically, the facility did not implement adequate behavior and side effect monitoring for residents administered various psychotropic medications, including fluoxetine, buspirone, trazodone, duloxetine, alprazolam, olanzapine, mirtazapine, sertraline, quetiapine, lorazepam, and clonazepam. The lack of proper monitoring and documentation led to the potential for medical interactions, adverse reactions, and unidentified risks associated with these medications, such as sedation, respiratory depression, constipation, anxiety, agitation, memory loss, and death. For instance, Resident 37 was administered fluoxetine for depression but did not have adequate behavior and side effect monitoring. Similarly, Resident 17 was given buspirone and trazodone without resident-specific non-pharmacological interventions and adequate behavior monitoring. Resident 7 received duloxetine, alprazolam, and olanzapine without proper non-pharmacological interventions and behavior monitoring. Additionally, Resident 50 was administered mirtazapine without adequate behavior monitoring and non-pharmacological interventions. The facility also failed to provide resident-specific non-pharmacological interventions and measurable objective goals for several residents, including Residents 41, 34, 16, 11, 26, and 2. For example, Resident 41 was given trazodone and sertraline without adequate behavior monitoring and non-pharmacological interventions. Resident 34 was administered quetiapine without proper behavioral monitoring and manufacturer-specified monitoring. Furthermore, Resident 16 received quetiapine and lorazepam without adequate side effect monitoring. These deficiencies were acknowledged by the Interim Director of Nursing, who stated that the facility was working on addressing these issues.
Failure to Maintain Proper Sanitation in Ice Machine and Dishwashing Machine
Penalty
Summary
The facility failed to ensure food and ice were stored in accordance with professional standards for food service safety. During an observation, it was found that the ice machine was not sanitized according to the manufacturer's directions. The Environmental Services Director (ESD) admitted that step 16 of the cleaning/sanitizing procedure, which involves adding the proper amount of ice machine sanitizer, was missed. Additionally, a brown/black substance was found on the bottom lip of the ice machine, indicating improper cleaning. The contract company responsible for servicing the ice machine also confirmed that they had not been using the required sanitizer as per the manufacturer's directions. In another observation, the dishwashing machine was found to be operating below the required temperature for the rinse cycle. The machine's rinse cycle temperature did not reach the manufacturer's specification of 180 degrees Fahrenheit, with multiple cycles showing temperatures between 160-178 degrees Fahrenheit. The Dietary Supervisor (DS) and Kitchen Aid 2 (KA2) both validated that the rinse temperature did not meet the required standards. The facility's policy and procedure, as well as the Dish Machine Temperature Log, indicated that the rinse temperature should be at least 180 degrees Fahrenheit, which was not achieved. These failures in maintaining proper sanitation procedures for the ice machine and dishwashing machine had the potential to result in the growth of microorganisms, posing a risk of foodborne illnesses for the 63 residents eating and drinking in the facility. The facility's policies and procedures were not followed, leading to these deficiencies in food service safety.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consents were obtained for the use of psychotropic medications for four residents. Resident 2 received Olanzapine without an informed consent. The resident's records showed that the medication was administered daily, but the required consent forms were incomplete, lacking signatures from both the resident or their representative and the physician. The Interim Director of Nursing confirmed that the current process did not require the resident or their representative to sign the consent form after being informed by the physician, which is against the facility's policy and procedure for antipsychotic medication use. Resident 34 was administered Quetiapine without an informed consent. The resident's records indicated that the medication was given on multiple occasions, but the consent form was missing the resident's signature. The Licensed Vocational Nurse confirmed that the resident or their representative did not sign anything, and the Interim Director of Nursing acknowledged that the physician did not document the discussion of risks and benefits with the resident or their representative. Resident 41 received Trazodone HCl and Resident 50 received Mirtazapine without informed consents. Both residents' records showed that the medications were administered regularly, but the consent forms were incomplete, missing signatures and indications for use. The Interim Director of Nursing stated that the current consents were missing physician documentation of the risks and benefits of the proposed medications and that the process did not require the resident or their representative to sign the consent form. The facility's policy and procedure require that residents and their representatives be informed of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use, which was not followed in these cases.
Failure to Provide a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as evidenced by multiple deficiencies observed in the living conditions. Residents 1, 7, 26, and 271's shared bathroom had blackened floor tiles, dirt on the floor, a loose doorknob, missing paint, chipped areas on the lower bathroom door frame, and scattered black areas on the bathroom ceiling, which were suspected to be mold. The Infection Preventionist (IP) and the Environmental Services Director (ESD) confirmed these issues, noting that the black spots could cause respiratory issues and different illnesses. The ESD also mentioned an air conditioner leak as a possible cause of the mold and stated that repairs were communicated through an electronic maintenance system but not logged in a written logbook. Resident 29 and 53's joint bathroom had a discolored ceiling with bubbling and peeling paint, which was suspected to be due to water leakage. The Licensed Vocational Nurse (LVN), Administrator (ADM), and ESD all acknowledged that the stains and peeling paint did not contribute to a homelike environment and needed to be repaired. Similarly, Resident 35's room had a wall guard protector with peeling paint and a large hole, which the LVN and ESD agreed could cause potential injury and was not acceptable for a homelike environment. Additional deficiencies included Resident 39's room, which had an exposed floor with missing tiles and visible dirt, and Resident 45's bathroom, which had dirt, a yellow spot on the floor, a dirty toilet, and a chipped lower door frame. Resident 48's bathroom had low water pressure, with water trickling out of the faucet and peeling paint with exposed drywall. The Interim Director of Nurses (IDON) confirmed that these conditions were not conducive to a homelike environment and could lead to potential infections. The facility's policies and procedures emphasized the importance of maintaining a clean, safe, and homelike environment, but these standards were not met in the observed cases.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for four residents. Resident 45 did not have an individualized care plan for severe weight loss until 41 days after admission, despite having a documented 5% or more weight loss in the last month. This delay in care planning was confirmed by the Director of Nursing during a record review. Resident 11 did not have a person-centered care plan to address his dental needs, despite repeatedly requesting help with obtaining dentures to aid in eating. The Licensed Vocational Nurse and Social Services Director were aware of the resident's request but failed to document it or include it in the care plan. This oversight left Resident 11's dental and nutritional needs unmet. Residents 41 and 44 did not have care plans to address the use of oxygen therapy. Resident 44 was observed using oxygen without a physician's order, and Resident 41 had an oxygen concentrator in his room without a corresponding care plan. The Interim Director of Nursing confirmed that care plans should be initiated within 14 days of admission and updated as needed, but this was not done for these residents.
Failure to Follow Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for three residents. Licensed Nurses (LNs) administered oxygen therapy to two residents without physician orders. Resident 41, who had a history of COVID-19 and nicotine dependence, was observed using an oxygen concentrator without a physician's order documented in the Electronic Medical Record (EMR). Similarly, Resident 44, who had diagnoses including dependence on renal dialysis, anemia, and congestive heart failure, was observed using oxygen therapy without a physician's order. Staff confirmed that Resident 44 often returned from dialysis with oxygen therapy applied as needed during transportation, but no formal orders were present in the EMR for this treatment. Facility policy requires a physician's order for oxygen administration, which was not followed in these cases. Additionally, the facility did not properly label and store oxygen tubing to prevent contamination for three residents. Resident 11, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and chronic respiratory failure, had unlabeled oxygen tubing and a breathing treatment mask laying on the nightstand. Resident 41 and Resident 44 also had unlabeled and improperly stored oxygen tubing. Observations revealed that the oxygen tubing was not dated and was not kept in protective coverings, such as bags, when not in use. Staff interviews confirmed that the tubing should be dated and stored in bags to prevent bacterial contamination, but these procedures were not consistently followed. The facility's policies and procedures for oxygen administration and infection control were not adhered to, resulting in residents receiving unnecessary oxygen treatment and the potential for infection from contaminated oxygen tubing. The Interim Director of Nursing (IDON) acknowledged that the tubing should be labeled and stored properly to ensure resident safety. Professional references and facility policies emphasize the importance of maintaining clean and properly managed oxygen supplies to prevent infection and ensure appropriate use of oxygen therapy.
Failure to Ensure Staff Competency and Training
Penalty
Summary
The facility failed to provide sufficient staff with the appropriate competencies and skill sets to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being. One of seven Licensed Vocational Nurses (LVNs) did not receive a blood glucometer competency skills check-off after being hired, which had the potential to expose residents to the spread of infections. Additionally, four of seven LVNs did not complete their required mandatory annual competency trainings, and one of five Certified Nursing Assistants (CNAs) did not receive a competency skills check-off after being hired. Furthermore, two of five CNAs did not complete their required mandatory annual competency trainings, placing residents at risk for care not provided in a safe and competent manner. During interviews and record reviews, it was revealed that the Director of Staff Development (DSD) and the Interim Director of Nursing (IDON) acknowledged the importance of mandatory competency training upon hire and annually. However, the records indicated that LVN 8 had not completed her blood glucometer competency, and LVNs 4, 8, and 9 had not completed their annual competency trainings. The DSD admitted that she did not keep track of CNA hours of training, and CNA 18 did not have an initial skills check-off or mandatory annual training documented in her personnel folder. CNA 9's annual skills check and evaluation were last completed in 2018, and the DSD stated that the annual skills check for CNA 9 was due in July 2024. The facility's policies and procedures required all personnel to participate in regular in-service education, including training that addresses the care of residents with cognitive impairment, dementia management, and resident abuse prevention. The policies also mandated that training requirements be met prior to staff providing services to residents, annually, and as necessary. Despite these requirements, the facility failed to ensure that staff completed their competencies and training on time, as evidenced by the incomplete records and interviews with the DSD and IDON.
Incomplete POLST Forms for Two Residents
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for two residents. Resident 23's Physician Orders for Life-Sustaining Treatment (POLST) was missing the date of the physician's signature, and Resident 31's POLST was missing the physician, physician assistant's license number, or Nurse Practitioner Certification number and physician signature date. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15, which means they were capable of making informed decisions about their care. Interviews with the Medical Records Director and the Interim Director of Nursing confirmed that the POLST forms were incomplete, which could potentially affect the residents' end-of-life care wishes. The Licensed Vocational Nurse (LVN) and the Interim Director of Nursing emphasized the importance of having complete POLST forms to ensure that the residents' treatment preferences are honored, especially in emergency situations or when transferred to another facility. The facility's job description for medical records staff includes monitoring resident charts to ensure all entries are complete and made in a timely manner, but this was not adhered to in these cases.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to help prevent diseases and infections. One resident's oxygen nasal cannula was found on the floor and part of the tube was laying on top of a garbage can. Staff interviews confirmed that the oxygen tubing should not be on the floor or touching the garbage, as this could potentially cause bacterial contamination. The facility's policy indicated that respiratory therapy equipment should be free from all microorganisms, but this was not adhered to in this instance. Three oxygen concentrators and filters were visibly soiled with dust and debris and were not cleaned according to the manufacturer's recommendations. Staff interviews revealed that the oxygen tubing should be kept in a bag to prevent contamination and that the filters should be cleaned regularly. However, the maintenance and cleaning protocols were not followed, putting residents at risk of infection. The central nurses' station countertop was peeling, cracked, and missing veneer, making it non-wipeable and potentially harboring bacteria. Additionally, the facility did not have a Legionella water testing protocol, nor did they perform Legionella water testing. One medication cart was visibly soiled with drip marks, and two pill crushers were encrusted with powder-like substances. Staff interviews confirmed that these items should be cleaned regularly to prevent contamination and infection, but this was not done, leading to potential health risks for the residents.
Failure to Implement and Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for new and existing Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), and ancillary support staff. This deficiency was identified through interviews and record reviews, revealing that several staff members had not completed required training in areas such as abuse, neglect, exploitation, dementia, communication, resident rights, infection control, and falls. Specifically, LVN 4 had no competency training for 2024, CNA 18 had outdated training records, and the MDS Coordinator had incomplete orientation and training records. Additionally, LVN 8 and LVN 9 were overdue for their yearly training, and CNA 9's annual skills check/evaluation was last completed in July 2018. The Director of Staff Development (DSD) and the Interim Director of Nursing (IDON) acknowledged the importance of these trainings in ensuring staff competency and resident safety. However, they admitted that the required training and competencies were not completed on time. The DSD also stated that she did not keep track of the required training hours for CNAs and did not conduct exit interviews to report to Quality Assurance and Performance Improvement (QAPI). The IDON emphasized the significance of annual staff competencies in maintaining the quality of care for residents, particularly those with dementia, and acknowledged his ultimate responsibility for ensuring staff training. The facility's policies and procedures mandated regular in-service education, including training on dementia management, abuse prevention, infection control, and resident rights. Despite these requirements, the facility failed to document and ensure the completion of these trainings. The lack of proper training and documentation had the potential to place residents at risk for care not provided in a safe and competent manner, as evidenced by the large population of residents with dementia and the critical need for staff to be well-trained in handling such conditions.
Failure to Timely Address Severe Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for Resident 45. This resident experienced a severe unplanned weight loss of 22 pounds or 11.2% of their admitting weight over 41 days. The Nutrition Assessment was not completed in a timely manner, leading to a delay in addressing the resident's compromised nutritional status. This delay could potentially lead to further medical complications, including dehydration and loss of muscle mass, which could negatively affect the resident's diagnoses and reasons for admission to the facility. Observations and interviews revealed that Resident 45 had a poor appetite and was not consuming sufficient food. During meal observations, the resident was noted to eat very little, and the bed was not elevated to an appropriate height for eating. The resident's weight records showed a significant and rapid weight loss, but the care plan to address this issue was not implemented until 4/16/24, despite earlier indications of weight loss. The Registered Dietitian (RD) did not complete the nutritional assessment until 41 days after admission, and the only intervention during this period was the provision of a house supplement and lab work ordered on 4/5/24. The Director of Nursing (DON) confirmed that the nutritional assessment and care plan were completed late and acknowledged that this was not acceptable practice. The facility's policies and procedures indicated that nutritional assessments should be conducted as part of the comprehensive assessment and that any significant weight changes should be evaluated by the treatment team. However, these procedures were not followed in the case of Resident 45, leading to a delay in addressing the resident's nutritional needs and potentially compromising their health further.
Failure to Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that one of five residents was offered or administered the pneumonia vaccine. During a concurrent interview and record review, it was found that Resident 16's Electronic Medical Record (EMR) did not contain any records of the pneumonia vaccine being given since admission. The Infection Preventionist (IP) confirmed that there were no past records of the resident receiving or refusing the pneumonia vaccine, and a declination form should have been signed if the vaccine was offered and refused. Resident 16 had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. The Director of Nurses (DON) stated that consents showing acceptance or refusals for immunizations must be signed by the resident or their responsible party (RP). A review of the facility's policy and procedure (P&P) titled
Facility Fails to Maintain Kitchen Flooring and Bathroom Ceiling
Penalty
Summary
The facility failed to maintain the physical environment in the kitchen and a shared bathroom, leading to potential health risks for residents. In the kitchen, multiple sections of the epoxy flooring were missing, revealing cement-like surfaces with old flooring remains and dark, unidentifiable substances. These areas were not smooth or easily cleanable, resulting in a buildup of food particles and debris. The Environmental Services Director (ESD) acknowledged the issue and mentioned that quotes for floor repairs were being sought, but no documentation was provided. The Registered Dietitian (RD) also noted that kitchen sanitation inspections were being conducted quarterly but would be changed to monthly. In the shared bathroom used by four residents, the ceiling had blackened areas and a hole, which were suspected to be mold due to a leak from the HVAC unit. The Infection Preventionist (IP) and the Administrator (ADM) confirmed the presence of black spots and a hole in the ceiling, with the IP stating that the black spots could cause respiratory distress and illnesses. The ESD admitted that the black spots were discovered about three weeks to a month ago but had not been repaired. The HVAC Vendor (ACV) also confirmed a similar water leak in the ceiling from the condensation pan. The facility's policies and procedures for maintenance were reviewed, indicating that the Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner. However, the ESD did not keep a maintenance log for the HVAC unit, and there was no documentation of the HVAC vendor's recent service. The facility's job duties for the ESD and the maintenance policies emphasized the importance of regular inspections and maintaining a schedule of maintenance services, which were not adequately followed in this case.
Loose Handrails in Hallway
Penalty
Summary
The facility failed to ensure that the handrail in one of three hallways was firmly secured to the wall, which had the potential to result in injury to residents, visitors, and staff. During an observation and interview with a Certified Nursing Assistant (CNA) in the Hollywood BLVD hallway, it was noted that the handrail between certain rooms was loose and moved back and forth. The CNA confirmed that the handrail was not safe for residents to hold on to. Further observation and interview with the Environmental Service Director (ESD) confirmed that the handrails were loose and needed to be tightened, acknowledging the potential risk of injury if the rails came off while in use by residents. The Director of Nursing (DON) also confirmed that the loose handrails should have been fixed and acknowledged the potential risk of a resident falling due to the loose rails. The Administrator (ADM) reiterated that loose handrails are not safe and could lead to falls for residents or staff. The facility's policy and procedure, titled Maintenance Service, dated December 2009, indicated that the maintenance department is responsible for maintaining the building and equipment in a safe and operable manner at all times. The policy emphasized maintaining the building in good repair and free from hazards. Additionally, a review of the professional standard from the Legal Information Institute titled Cal. Code Regs. Tit. 22, S 72635-Handrails, indicated that corridors shall be equipped with firmly secured handrails as required by Section T17-058I, Title 24. The facility's failure to adhere to these standards and policies led to the deficiency observed by the surveyors.
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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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