Laguna Honda Hospital & Rehabilitation Ctr D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 375 Laguna Honda Blvd., San Francisco, California 94116
- CMS Provider Number
- 555929
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Laguna Honda Hospital & Rehabilitation Ctr D/p Snf during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
The facility did not report four allegations of abuse to CDPH within the required two-hour timeframe. In two separate incidents, staff observed inappropriate or abusive interactions between residents with cognitive impairments, but delayed reporting due to internal decisions and confusion about reporting requirements, despite facility policy mandating immediate notification to authorities.
Surveyors found that an outdoor garbage bin near the kitchen was left open and filled to the top with used food containers, while over 60 compost and recycle bins behind the kitchen had visible black residue, food waste, and attracted flies. Facility leadership confirmed the bins were not clean and that cleaning occurred only monthly, failing to meet federal requirements for refuse management.
Surveyors observed small flies in multiple kitchen areas, including near refuse and food production zones. Staff documented and reported the issue, and pest control serviced the area regularly, but the fly problem persisted and was not effectively eliminated, as confirmed by the FSD and FSS.
A resident with quadriplegia and a history of stimulant use disorder refused a physician-ordered urine toxicology screen, as documented by staff. Despite this refusal, staff collected and sent a urine sample for testing, violating the resident's right to make medical decisions about their care.
A resident with impaired mobility, left hemiparesis, and dysphagia was found self-administering Metamucil at bedside without proper assessment, physician order, or care plan in place. Nursing staff left the medication at the bedside and did not ensure the full dose was taken, contrary to facility policy requiring interdisciplinary assessment and documentation before allowing self-administration.
A resident admitted with complex medical conditions did not have a baseline care plan for ADL oral care developed within 48 hours, as required by facility policy. Staff interviews confirmed the delay, and records showed the dental care plan was initiated several days after admission, resulting in a lapse in timely care planning.
The facility did not follow physician orders for oxygen therapy and medication administration for three residents. One resident received oxygen at an incorrect flow rate and without proper documentation of oxygen saturation. Another resident was given Glipizide after breakfast instead of before, as ordered. A third resident had a Lidocaine patch applied to the wrong body area, contrary to the prescriber's instructions. These actions did not meet professional standards of quality.
A resident's Methadone Concentrate waste was improperly disposed of by an RN, who placed both the medication and measuring cup into a container for non-controlled pharmaceutical waste instead of using the designated RX Destroyer for controlled substances. This action was confirmed through staff interviews and was not in accordance with facility policy, which requires controlled substances to be disposed of in the RX Destroyer.
Kitchen staff failed to follow manufacturer instructions for testing sanitizer strength on food contact surfaces, with improper immersion times and immediate color comparison instead of the required procedure. In-service training did not cover the correct method, and facility policy lacked specific guidance, resulting in staff not being competent in accurate sanitizer testing.
Surveyors found that two residents' food items, including deli meat and frozen products, were not stored or labeled according to manufacturer instructions. Opened lunch meat was kept beyond the recommended period without proper labeling of the open date, and frozen foods were stored in a refrigerator instead of a freezer. Nursing staff and the FSD confirmed these practices, and facility policy requiring adherence to manufacturer guidelines was not followed.
The facility failed to maintain kitchen sanitation standards, including cracked tiles and dust build-up, improper sanitization of steam jacket kettles, and uncovered frozen food items. Additionally, a resident's egg-salad sandwich was not discarded within the appropriate time frame, posing a risk of food poisoning.
The facility's kitchen had a persistent fruit fly infestation, with flies observed in the warewashing room above trash and compost bins. Despite weekly pest control services, reports consistently documented the presence of fruit flies from August to October. The Pest Control Technician indicated that additional measures were needed to address the issue, as current efforts were insufficient.
A facility failed to develop a comprehensive care plan for a resident on comfort care, who was admitted with seizure and brain injury. The resident was observed with oxygen and not verbally responsive. Despite having a DNR/DNI status and comfort-based goals of care, the care plan lacked documentation of comfort care, contrary to facility policy.
A resident with swallowing difficulties was not reassessed by an SLP after an esophageal dilation procedure, despite recommendations to continue a puree diet and thin liquids. The resident, with conditions including paraplegia and schizophrenia, was maintained on a regular diet, accepting the risk of aspiration, contrary to the SLP's advice.
A facility failed to document a clinical rationale for a PRN Ativan prescription exceeding 14 days for a resident with paraplegia, epilepsy, and insomnia. Initially, the order lacked justification, contrary to facility policy. Later, a doctor modified the order, citing chronic insomnia as the reason for the extended duration.
The facility exceeded the acceptable medication error rate with a 6% error rate during a medication pass. An LVN administered insulin at an incorrect angle, and an RN failed to rotate insulin injection sites for two residents. These actions contradict recommended practices for insulin administration.
A resident with Peripheral Vascular Disease and other medical conditions did not receive foot care for over three months, resulting in long, painful toenails. Despite a podiatry referral, the facility failed to initiate care, and the resident was unaware of available services. Observations showed excessively long nails, and the unit manager could not explain the neglect, violating the facility's foot care policy.
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in their care. Specific issues included the lack of care plans for medical conditions, medications, and necessary interventions, as well as inconsistent implementation and documentation of care plan interventions.
The facility failed to provide a safe environment by not properly documenting and monitoring Aero Scout devices for two residents, increasing the risk of elopement. Additionally, the facility did not follow the care plan for a resident requiring two staff members for assistance, resulting in a fall and hospitalization.
The facility failed to ensure a comprehensive infection prevention and control program, leading to multiple deficiencies including improper handling of contact precautions, failure to follow TB screening protocols, and inadequate cleaning procedures. These lapses increased the risk of spreading infections among residents.
The facility failed to maintain essential kitchen equipment and the physical environment, leading to water leaks from a dish machine, non-operational temperature gauges, missing grout in floor tiles, and improper maintenance of ice machines. Despite multiple work orders and monitoring claims, these issues persisted, indicating ongoing maintenance failures.
The facility failed to visually monitor a physical restraint device for a resident with Huntington's Disease, resulting in gaps in required documentation and potential safety risks. Staff interviews and record reviews confirmed the lack of consistent monitoring as per facility policy.
The facility failed to report an allegation of abuse within the required 2-hour timeframe. Two residents were involved in a physical altercation, and the incident was reported to the California Department of Public Health the next day. Regulatory Affairs Nurses believed the abuse was not intentional, leading to the delay. Facility policy mandates reporting within 2 hours.
The facility failed to update the care plan for a resident who received new dentures, resulting in the resident not wearing the dentures and PCAs being unable to provide proper care. The care plan did not include specific dental instructions, contrary to facility policy.
The facility failed to document specific dental care instructions for a resident's new dentures, leading to inconsistent care and the resident not wearing his dentures. The omission was identified during an observation and interview with the Nurse Manager, who confirmed that the instructions were not transcribed into the EHR as required by facility policy.
The facility failed to provide necessary mealtime assistance for a resident with left extremity weakness and dementia. The resident struggled to feed herself and open containers, and staff did not intervene to assist, despite the facility's policy requiring such assistance.
A skilled nursing facility failed to monitor and document the wound progression of a resident with a left lower leg infection. Despite treatment with antibiotics, staff did not record the wound's status for 21 days, making it difficult to assess its healing. Interviews revealed that nursing staff were aware of the infection but failed to document it, contrary to the facility's policy requiring weekly wound assessments.
The facility failed to provide and document Passive Range of Motion (PROM) exercises for a resident as per active orders, potentially impacting the resident's mobility and functional status. The Nursing Manager confirmed that PROM was not documented during the day shift on multiple dates.
The facility failed to maintain a medication error rate of less than 5%, with five errors observed out of fifty-five opportunities, resulting in a 9% error rate. Incidents included improper administration of Metformin without food, incorrect technique in administering eye drops, and failure to follow nasal spray administration policy.
The facility failed to respond to refrigerated temperature excursions for medications and did not document follow-up actions for several instances where storage temperatures deviated outside the acceptable range. Additionally, the facility failed to monitor the temperature of the medication room in the Pavilion Mezzanine skill nursing area, as there was no sensor installed. These failures could have compromised medication stability and patient safety.
The facility failed to ensure ready-to-eat foods from Vendor 1 met current food safety standards. Over 10 cases of such food were found in the walk-in refrigerator, and the Director of Food Services (DFS) admitted that no follow-up inspections had been conducted since a Registered Dietitian's visit 12-18 months ago. Despite a yearly review process, the facility had not requested additional information from the vendor regarding food safety concerns identified by the FDA in April 2023.
The facility failed to follow its policy on influenza immunizations for a resident, resulting in an incomplete medical record. Despite the resident stating that the vaccine was offered and refused twice, there was no documentation of the vaccine administration or refusal. The Director of Infection Prevention confirmed the absence of required documentation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to report four separate allegations of abuse within the required two-hour timeframe to the California Department of Public Health (CDPH). In one incident, two residents with significant cognitive impairments and BIMS scores of 0 were involved in a resident-to-resident sexual abuse event. Staff observed one resident attempting to open the brief of another resident during the night. Although the incident was reported internally, the team initially decided it was not reportable, and the mandated report to CDPH was delayed until a physician later determined it should be reported. In another incident, a staff member observed inappropriate touching between two residents in a common area. The staff member reported the event to the team leader, who dismissed the concern, stating that the residents were friends. The incident was later discussed in a team huddle, but there was confusion among staff about whether the event was reportable. The mandated report to CDPH and other agencies was delayed as the team attempted to contact the family of one resident and debated the necessity of reporting, despite facility policy requiring reporting within two hours. Facility policy clearly states that all employees, contractors, and volunteers are mandated reporters and must report alleged abuse to CDPH, the Ombudsman, and Nursing Operations within specified timeframes. However, in both cases, staff failed to adhere to these requirements, resulting in delayed reporting of abuse allegations. Interviews with staff and review of clinical notes confirmed that confusion about what constitutes a reportable event and internal decision-making processes contributed to the reporting delays.
Improper Disposal and Maintenance of Outdoor Refuse and Recycle Bins
Penalty
Summary
Surveyors observed that one outdoor garbage bin located near the kitchen loading dock was filled to the top with used food containers and had its lid left open. This was confirmed by the Food Service Director and the Director of Emergency Management, who acknowledged that the lid should have been closed. Additionally, over 60 compost and recycle bins stored behind the kitchen were found to have black residue on both the inside and outside surfaces, with flies present around the bins. Several bins were opened and found to contain empty food containers, food residue, and garbage, with the inside surfaces covered in black residue and some bins being wet inside. The Executive Director of Facility Services confirmed that the bins were not clean, and the Director of Emergency Management stated that the bins were emptied once daily and pressure washed once per month. According to the 2022 Federal Food Code, outdoor refuse, recyclables, and returnables receptacles are required to have tight-fitting lids and be cleaned frequently enough to prevent buildup and attraction of pests. The facility failed to meet these requirements, as evidenced by the open garbage bin and unclean recycle and compost bins.
Failure to Maintain Kitchen Free from Flies
Penalty
Summary
The facility failed to maintain the kitchen free from flies, as observed during multiple inspections. On several occasions, small flies were seen on the ceiling and walls in the dish machine room, particularly around bins for shredded paper, refuse, and recycling, as well as in the food production and trayline areas. The Food Service Director (FSD) confirmed the presence of flies and was unaware of their occurrence until notified. Although the pest control company serviced the kitchen three times a week, specific actions to eliminate the flies were not taken when fly activity was identified. Documentation and interviews revealed that staff, including the Food Service Supervisor (FSS), regularly identified and documented the presence of flies and placed work orders for pest control intervention. Work orders and inspection checklists confirmed repeated sightings and pest control responses, such as vacuuming fruit flies. However, despite these reports and interventions, the fly problem persisted, and there was uncertainty about whether all necessary work orders were consistently placed. The ongoing presence of flies in food preparation and storage areas was not effectively addressed, as required by the 2022 Federal Food Code.
Resident's Right to Refuse Urine Toxicology Test Not Honored
Penalty
Summary
A cognitively intact resident with quadriplegia, chronic pain syndrome, and a history of stimulant use disorder was admitted to the facility and had a physician's order for a urine toxicology screen. According to nursing notes and staff interviews, the resident refused the urine toxicology test, and this refusal was documented in the electronic health record. Despite the resident's refusal, staff proceeded to collect a urine sample and sent it to the laboratory for toxicology screening, which later returned positive for amphetamines. Interviews with nursing staff confirmed that the resident's right to refuse the test was not honored, even though facility policy requires resident rights to be protected and promoted. The resident was alert, oriented, and able to communicate his wishes, explicitly stating that he had refused the test. The facility's actions resulted in a violation of the resident's right to make medical decisions regarding their care and treatment.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis, and dysphagia was observed self-administering Metamucil mixed with orange juice at their bedside. The medication was left at the bedside, and the resident consumed it at their own pace without direct observation by nursing staff. The resident was not assessed or approved for self-administration of medication, and there was no physician's order, care plan, or interdisciplinary team documentation authorizing self-administration. The facility's policy required an assessment and care plan before allowing bedside medication storage and self-administration, which was not followed in this case. Nursing staff acknowledged that the resident could not open the medication packet independently and did not consume the medication in a timely manner. The nurse manager confirmed that the resident had not been assessed for self-administration capability and that the medication was left at the bedside without ensuring the full dose was taken. The lack of assessment and authorization for self-administration, combined with the resident's medical conditions, resulted in a failure to appropriately administer medication as required by facility policy.
Failure to Develop Baseline Care Plan for ADL Oral Care Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, specifically regarding activities of daily living (ADL) for oral care. The resident was admitted with multiple diagnoses, including stroke, dysphagia, heart failure, aphasia, and systemic lupus erythematosus. Interviews with facility staff confirmed that the baseline assessment and care plan, which should have been completed within 48 hours as per facility policy, were not developed in the required timeframe. Staff also indicated that without the care plan, essential ADL care such as oral care would not be performed, as they rely on the care plan for daily care instructions. Review of the clinical record showed that the dental care plan was not initiated until several days after admission.
Failure to Follow Physician Orders for Oxygen and Medication Administration
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of quality in several instances. One resident with chronic obstructive pulmonary disease (COPD) and a history of obstructive sleep apnea was observed receiving oxygen therapy at a rate of 1 liter per minute via nasal cannula, contrary to the physician's order for 2 liters per minute as needed to maintain oxygen saturation above 92%. Documentation of oxygen saturation was not completed on the day of observation, and the last recorded value was two days prior. The care plan and facility policy required adherence to the physician's order and proper documentation, which was not followed. In another instance, a resident prescribed Glipizide 10 mg tablet for type 2 diabetes mellitus was administered the medication after breakfast, despite the physician's order specifying administration before breakfast. The nurse confirmed that the medication was given at the incorrect time, as breakfast had already been completed prior to administration. This action was not in accordance with the prescriber's parameters for medication timing. Additionally, a resident with an order for two Lidocaine 5% patches to be applied to the right shoulder and right rib area for pain received one patch incorrectly applied to the mid-lower back. The nurse acknowledged the error and corrected the application after it was identified. The facility's policy on medication administration required adherence to the six rights, including correct route and site, which was not followed in this case.
Improper Disposal of Controlled Substance Documented
Penalty
Summary
The facility failed to accurately dispose of and record the disposal of a controlled drug, specifically Methadone Concentrate, for one resident. During an observation in the medication room, an Omnicell receipt showed that 90 mg of Methadone was administered and 10 mg was wasted for the resident. The waste was witnessed and documented by two registered nurses. However, the nurse responsible for the disposal described placing both the 10 mg of Methadone and the measuring cup into a black container designated for non-controlled pharmaceutical waste, rather than using the PRO SERIES RX Destroyer, which is specifically labeled for controlled substance waste. This process was confirmed by the nurse during an interview. Further interviews with nursing staff confirmed that the correct procedure, as outlined in the facility's policy, requires controlled substances like Methadone to be disposed of in the RX Destroyer, with only the measuring cup being placed in the non-controlled waste container. The nurse did not follow this protocol, and the error was acknowledged by supervisory staff. The facility's policy, last revised in February 2025, clearly states that controlled substances must be disposed of in the RX Destroyer located in the medication rooms.
Improper Sanitizer Testing by Food Service Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in testing the sanitizer strength used for sanitizing food contact surfaces. During an observation and interview, the Food Service Supervisor (FSS) demonstrated improper technique by immersing the test strip in the sanitizer solution for 20-21 seconds and immediately comparing the color, instead of following the manufacturer's instructions to immerse for 5 seconds and evaluate the color 10 seconds after removal. When questioned, the FSS stated the strip should be held for about 10 seconds, which was also incorrect according to the manufacturer's label. A review of facility documents showed that the FSS had attended an in-service training on the Three Bucket Sanitizing Method, but the training did not include specific instructions on how long to immerse the test strip. The facility's policy required supervisors or designated staff to test sanitizer concentration twice daily, but did not specify the correct procedure as per the manufacturer's instructions. This lack of proper training and adherence to manufacturer guidelines resulted in the staff not being competent in accurately testing sanitizer strength, potentially compromising infection control and resident safety.
Improper Storage and Labeling of Resident Food Items
Penalty
Summary
Surveyors observed that food stored in a resident refrigerator located in a great room was not managed according to professional food safety standards. Specifically, an opened package of sliced ham was found with a facility-applied expiration label matching the manufacturer’s expiration date, but the package instructions required use within seven days of opening. The facility’s labeling did not indicate the date the package was opened, and nursing staff confirmed they used the manufacturer’s expiration date rather than the open date for discarding lunch meat. The Food Service Director (FSD) confirmed that the manufacturer’s instructions should be followed and referenced FDA guidelines recommending a shorter storage period after opening. Additionally, the same refrigerator contained a turkey pot pie and a box of Uncrustables sandwiches, both of which were labeled by the facility but stored in a refrigerator rather than a freezer, contrary to the manufacturer’s instructions to keep these items frozen until use. Nursing staff confirmed that the great rooms only had refrigerators and not freezers, and the FSD stated he was unsure where residents’ personal frozen foods should be stored, expressing concerns about cross-contamination if stored in galley kitchens. Facility policies required food from outside sources to be stored and discarded according to manufacturer recommendations, but these procedures were not followed for the observed items.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen floor in the steam jacket kettle area, resulting in cracked tiles and missing grout. During an observation, it was noted that the floor was wet, and water seeped out from beneath the tiles when pressure was applied. The Food Service Director (FSD) acknowledged that a work order had been placed weeks prior to address the issue, but the problem persisted. The Director of Facilities confirmed the broken tiles and missing grout, indicating that the area needed to be resurfaced with a more durable material. The facility also failed to maintain the ceiling above the manual dishwashing area, which had a significant dust build-up. The FSD admitted that the ceiling was cleaned only once a year, and the last cleaning was done several months ago. This lack of regular maintenance could lead to the growth of microorganisms and potential contamination of food. Additionally, the facility did not sanitize steam jacket kettles as part of the cleaning process. A Food Service Worker responsible for cleaning the kettles confirmed that the sanitizing step was omitted, which was against the facility's policy. Furthermore, frozen food items were not properly covered in the freezer, increasing the risk of cross-contamination. During an inspection, multiple uncovered food items were found in the walk-in freezer. The FSD acknowledged the oversight and admitted that the facility could improve its food storage practices. Additionally, an egg-salad sandwich served to a resident was not discarded within the appropriate time frame, posing a risk of food poisoning. The sandwich, served the previous night, was still present in the resident's room the following morning, which was confirmed by the Nurse Supervisor.
Persistent Fruit Fly Infestation in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the consistent presence of fruit flies. During an initial tour of the kitchen, small flies were observed on the ceiling in the warewashing room, particularly above the trash and compost bins. The Food Service Director confirmed the presence of these flies and noted that a pest control technician serviced the kitchen weekly. However, pest reports from August to October consistently documented the presence of fruit flies, indicating an ongoing issue that had not been effectively addressed. Interviews with the Environmental Services Director and the Pest Control Technician revealed that a work order for the flies was submitted, but the issue persisted. The Pest Control Technician explained that the presence of breeding material, such as food residue, promoted the presence of fruit flies. Despite weekly services, the technician suggested that additional measures, such as increased service frequency or the use of pesticides in drains, were necessary to eliminate the flies. The facility's current pest control measures were insufficient to address the problem, leading to a potential risk of contamination in the kitchen.
Failure to Develop Comprehensive Care Plan for Comfort Care
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 62, who was admitted with a diagnosis including seizure and brain injury. During an observation, Resident 62 was found in bed with oxygen via nasal cannula and was not verbally responsive. An interview and record review with the Nurse Manager revealed that Resident 62 was on comfort care, as indicated by the Health Care Advance Directive and Advanced Care Planning, which stated the goals of care were comfort-based with a DNR/DNI status. However, a review of the resident's care plan showed no documentation of comfort care, which was acknowledged by the Nurse Manager as an oversight. The facility's policy requires a comprehensive person-centered care plan that includes advance care planning and palliative care, which was not met in this case.
Failure to Follow SLP Recommendations for Resident's Diet
Penalty
Summary
The facility failed to adhere to the recommendations of a speech language pathologist (SLP) for a resident with swallowing difficulties. The SLP had recommended that the resident continue on a puree diet and thin liquids until a reassessment could be conducted following an esophageal dilation procedure. However, the resident was maintained on a regular diet without the necessary reassessment by an SLP, which could lead to an inaccurate assessment of the resident's swallowing ability. The resident in question had multiple medical issues, including paraplegia and schizophrenia, and underwent an esophagogastroduodenoscopy (EGD) where the esophagus was dilated. Despite the SLP's recommendations, the resident's care plan indicated that the resident accepted the risk of aspiration while on a regular diet. A physician's treatment plan document noted that the resident wanted to continue with a regular diet despite the risks of aspiration.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale for a PRN medication order of a psychotropic drug beyond 14 days for one of the residents. The resident, who was admitted in 2019, has medical conditions including paraplegia, epilepsy, and insomnia. The resident was prescribed Ativan, a sedating medication, for 90 days to manage sleep issues. However, the facility's policy requires that PRN non-antipsychotic medications be limited to 14 days unless a longer duration is justified by a physician with documented rationale. This requirement was not initially met for the resident's Ativan prescription. During a review, it was found that the medication order for Ativan was initially documented without a specific reason for extending beyond 14 days. The pharmacist noted that the order might have been a typo, and there was no clear rationale provided. Upon further review, the medical doctor modified the order to include a rationale, stating that the resident's chronic insomnia with fluctuating frequency justified the PRN order for more than 14 days. The doctor noted that the benefits of quality rest outweighed the risks of the medication.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 6% during a medication pass. This was due to two medication errors out of thirty-two opportunities involving two residents. The first error involved a licensed vocational nurse (LVN 1) who administered 4 units of NPH insulin to a resident at an incorrect angle of approximately 20 degrees instead of the recommended 90 degrees. This improper technique could affect the insulin's effectiveness and the resident's blood glucose levels. LVN 1 acknowledged the mistake and the need to improve his injection technique. The second error involved a registered nurse (RN 1) who failed to rotate the insulin injection site for a resident with a blood sugar level of 334. The resident received 4 units of Lispro insulin in the right lower quadrant, the same site as the previous injection. This failure to rotate injection sites goes against the recommendations of the American Diabetes Association and the American Association of Diabetes Educators, which aim to prevent lipodystrophy and ensure consistent insulin absorption. The nurse confirmed the oversight, and the Nurse Educator stated that there is a protocol in place to ensure proper rotation of injection sites.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care to a resident, resulting in long, crooked, and jagged toenails that caused the resident pain and discomfort. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, a left foot wound, and dementia, had not received foot or hand care for over three months. During an office visit, it was noted that all ten toenails were long, and the resident complained of pain in the left foot. Despite a podiatry referral being ordered, it was not initiated, and the resident remained unaware that foot and fingernail care could be provided at the facility. Observations and interviews revealed that the resident's toenails and fingernails were excessively long, with the right thumbnail being approximately two inches long. The resident expressed discomfort and a lack of knowledge about available care services. The unit manager could not provide a reason for the neglect in nail care. The facility's foot care policy outlines responsibilities for nursing assistants and licensed nurses in inspecting and maintaining foot health, but these procedures were not followed, leading to the deficiency.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in their care. For Resident 1153, there was no care plan addressing the diagnosis of Hepatic Encephalopathy or the use of rifAXIMin antibiotic, despite the resident's complex medical history including dementia, pneumonia, traumatic brain injury, and seizure disorder. The lack of a specific care plan for these conditions meant that nursing staff were not adequately informed about the necessary interventions and monitoring for medication effectiveness and side effects, potentially compromising the resident's health outcomes. Both the Registered Nurse and the Director of Nursing acknowledged the absence of these care plans and the risks associated with it during their interviews and record reviews. Resident 1151's care plan also lacked specific interventions for the use of Calamine Zinc Ointment to relieve itching, despite the resident's diagnoses of dementia, congestive heart failure, recurrent urinary tract infections, depression, and fragile skin. The Registered Nurse and the Director of Nursing confirmed that a care plan should have been created to monitor the effectiveness and side effects of the medication. Similarly, Resident 1253's care plan included an intervention for Passive Range of Motion (PROM) exercises, but these were not consistently implemented or documented, as confirmed by the Nursing Manager during a review of the resident's electronic health records. Other deficiencies included the absence of a care plan for the frequency of Range of Motion exercises for Resident 56, the failure to provide continuous close observation by an assigned coach for Resident 859, and the lack of care plans for a Peripherally Inserted Central Catheter (PICC) line and Contact Isolation Precautions for Resident 1303. These omissions were confirmed through interviews with nursing staff and record reviews, highlighting a systemic issue in the facility's care planning process. The facility's policies and procedures were not followed, leading to potential risks for the residents involved.
Failure to Monitor Aero Scout Devices and Follow Care Plan
Penalty
Summary
The facility failed to provide a safe environment for three residents by not properly documenting and monitoring the placement and function of Aero Scout devices, which are used to monitor wandering patients. For Resident 61, who was admitted with dementia, there were multiple instances of missing documentation regarding the Aero Scout device. Staff interviews revealed that they did not regularly check the bracelets or keep a log of their status. The Resident Asset List (RAL) and Resident Asset List Audit (RALA) showed numerous dates with no documentation, confirming the lack of monitoring. Resident 61's care plan indicated a high elopement risk, requiring Aero Scout monitoring every shift, which was not adhered to by the staff. Similarly, Resident 1302, who had a traumatic brain injury and severe cognitive impairment, also had missing documentation for the Aero Scout device. Staff interviews confirmed that the functionality of the Aero Scout was not individually monitored or documented for each resident. The facility's policy required every shift to verify the placement and functionality of the Aero Scout, but this was not consistently done, increasing the risk of elopement for Resident 1302. Additionally, the facility failed to follow the care plan for Resident 805, who required two staff members for assistance during care. On one occasion, only one PCA was present, resulting in the resident falling out of bed and being sent to the hospital. Interviews with staff revealed that they were not aware of the care plan requirements, and the PCA assigned to Resident 805 did not check the medical record to confirm the resident's needs. The facility's policy on change of shift hand-off was not followed, leading to inadequate communication about the resident's care needs.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to ensure the infection prevention and control program (IPCP) included a facility-wide program for the surveillance, prevention, and control of healthcare-associated infections (HAIs) and other infectious diseases. For Resident 1303, the facility did not follow their policy on contact precautions and encouraged group activities despite a physician's order for continuous contact precautions. The resident was observed participating in group activities without proper precautions, and there was no documentation of an interdisciplinary team assessment determining it was safe for the resident to do so. Additionally, the facility did not follow the manufacturer's instructions for the use of Oxivir Disinfectant Cleaner while performing environmental cleaning for Resident 451, as the treated area was not allowed to remain wet for the required one minute before placing items back on the cleaned surface. The facility also failed to follow their policy on Tuberculosis (TB) symptom screenings upon readmission for Residents 553 and 1303. There was no documentation that showed a TB symptom screening assessment was completed upon their readmission to the facility. Furthermore, the facility did not follow the manufacturer's instructions on cleaning and maintaining linen warming cabinets, as observed with Blanket Warmer 1, which contained contaminated blankets and debris. For Resident 355, postings for isolation precautions were not visible, and staff did not wear proper protective equipment when entering the resident's room. Staff were also unaware of the reason for transmission-based precautions. Additionally, the facility did not ensure that a staff member wore the proper personal protective equipment (PPE) upon entry into a contact and airborne precaution room for Resident 404. For Residents 460, 461, 462, and 463, the facility did not ensure that a staff member handled and distributed clean linen in a safe manner, as the staff member was observed carrying clean linen from room to room, which could contribute to the spread of infections. These failures created an increased risk of spreading infections and communicable diseases to the residents receiving care in the facility.
Maintenance Failures in Kitchen Equipment and Flooring
Penalty
Summary
The facility failed to ensure proper maintenance of essential kitchen equipment and the physical environment, leading to several deficiencies. One of the two dish machines in the kitchen had been leaking water from both the top and bottom for about a month. The final rinse temperature gauge on the dish machine was non-operational, and despite multiple work orders and attempts to fix the issues, the problems persisted. Observations revealed water pooling on and around the machine, and significant residue buildup, indicating ongoing maintenance failures. Interviews with the Food Service Supervisors and Facility Services staff confirmed that the issues were known but not resolved, with conflicting reports on the status of work orders and repairs. Additionally, the facility failed to maintain the integrity of the flooring in the hot and cold food production areas. More than ten tiles had missing grout, leading to the accumulation of moisture and food debris. This condition was observed during general dietetic services inspections, and interviews with the Director of Food Services and Food Service Supervisor revealed that while monitoring was claimed, there was no documentation to validate requests for floor repairs. The Chief Clinical Dietitian's monthly reviews did not identify these issues, and the facility's checklist for kitchen inspections was not effectively utilized. Furthermore, the preventive maintenance of the ice machines was inadequate. A flush tube for the ice machine filter was inserted directly into a soiled floor sink, which had a buildup of black slime and brown unidentified material. The placement of the ice machine and its plumbing made it difficult to clean the floor sink properly. These observations were confirmed during interviews with the Facilities Engineer and the Director of Food Services, highlighting a lack of proper maintenance and cleanliness in critical areas of the facility's dietetic services.
Failure to Monitor Physical Restraint Device
Penalty
Summary
The facility failed to visually monitor a physical restraint device for one resident, identified as Resident 1301, who had a seat belt type restraint used during the day when in his chair or wheelchair. Resident 1301, diagnosed with Huntington's Disease and severe cognitive impairment, was observed with a non-releasing seat belt across his lap while in a wheelchair. The facility's policy required visual checks every two hours, but documentation showed gaps on five specific days, indicating a failure to monitor the restraint as required. Interviews with staff confirmed the lack of consistent documentation and monitoring. A Patient Care Assistant and a Registered Nurse both acknowledged the need for every two-hour checks and documentation, but the flowsheet review revealed missing entries on multiple days. The facility's policy emphasized the importance of ongoing monitoring and documentation to ensure the resident's safety and prevent injury, but this was not adhered to, leading to the identified deficiency.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe. A review of Form SOC 341, dated 10/24/23, indicated that two residents were involved in a physical altercation on 10/23/23 at approximately 1 p.m. The report was submitted to the California Department of Public Health on 10/24/23 at 11:06 a.m., which was beyond the mandated 2-hour reporting window. During an interview on 11/30/23, Regulatory Affairs Nurses stated they believed the abuse was not intentional, which led to the delay in reporting. The facility's policy, dated 11/14/23, mandates that all allegations of abuse be reported within 2 hours.
Failure to Update Care Plan for New Dentures
Penalty
Summary
The facility failed to revise the care plan for a resident who received new dentures on July 21, 2023. This oversight resulted in the resident not being compliant with wearing his new dentures, and the Patient Care Assistants (PCAs) were unable to implement the specific care required for the new dentures. The care plan did not include the specific dental instructions provided by the resident's dentist, which were essential for proper denture maintenance and usage. During observations and interviews conducted on November 27, 28, and 29, 2023, it was noted that the resident was not wearing his dentures during meals and required reminders to use them. The resident's care plan, which should have been updated to reflect the new denture care instructions, remained unchanged from August 1, 2023, to November 1, 2023. The nursing staff acknowledged that the care plan was not updated as required when the resident received his new dentures. The facility's policy on Resident Care Plans mandates that care plans be person-centered, evaluated during weekly or monthly summaries, and revised as needed during changes in condition. However, this policy was not followed in the case of the resident's new dentures, leading to a deficiency in providing the necessary care and instructions for the resident's oral health needs.
Failure to Document Dental Care Instructions
Penalty
Summary
The facility failed to document specific dental care instructions for a resident who received new dentures. This omission was identified during an observation and interview with the Nurse Manager, where it was noted that the resident was not wearing his dentures and required reminders to use them before eating. The resident, who was cognitively intact and required total dependence on personal hygiene, had received detailed dental care instructions that were not transcribed into the facility's electronic health record (EHR). This failure prevented Patient Care Assistants from implementing the specific care needed for the resident's new dentures. The dental progress notes indicated that the resident had received complete maxillary and mandibular resin-based partial dentures, along with home care instructions. However, these instructions were not entered into the EHR, as confirmed by the Nurse Manager. The Patient Care Assistant who attended to the resident was unaware of the specific dental care instructions and followed a different cleaning routine, which included using a denture brush and cleaning tablets. This discrepancy in care routines was observed during multiple interviews and record reviews. The facility's policy on the transcription and processing of orders requires licensed nurses to acknowledge and transcribe orders prescribed during their shift. The Nurse Manager admitted that the dental instructions should have been transcribed into the EHR, allowing staff to view and implement the specific care required for the resident's dentures. The failure to document these instructions led to inconsistent care and the resident not wearing his dentures as needed.
Failure to Provide Necessary Mealtime Assistance
Penalty
Summary
The facility failed to provide necessary assistance during mealtime for one resident, identified as Resident 451. During lunch, Resident 451, who has a history of right thalamic hemorrhage with residual left extremity weakness and dementia, was observed struggling to feed herself. She was positioned sideways to her lunch tray and had difficulty opening a juice container, which she attempted to open with her teeth. The Certified Nursing Assistant (CNA 1) assigned to her did not intervene to assist. Similarly, during breakfast, Resident 451 was observed having difficulty eating pudding from a small container, which moved around the tray with each spoonful. CNA 2 acknowledged the difficulty but did not provide the necessary assistance. Both CNAs were not familiar with Resident 451's specific meal assistance needs. A review of Resident 451's clinical record indicated that she required setup assistance with meals. However, her care plans did not include specific personalized interventions for meal assistance. The Registered Nurse (RN 9) confirmed that staff were supposed to set up the meal tray and provide assistance when needed but was unaware of the resident's difficulties. The Nursing Supervisor (NS 2) mentioned that an Occupational Therapy referral should be ordered for residents with extremity weakness for possible adaptive devices. Resident 451 confirmed through a translator that she needed more assistance during meals. The facility's policy on assisting residents during mealtime was not followed, as it required staff to assist with opening containers and preparing food for eating, which was not done for Resident 451.
Failure to Monitor Wound Progression
Penalty
Summary
The skilled nursing facility failed to monitor wound progression for Resident 351, who had developed an infection on his left lower leg. Despite being treated with antibiotics for left lower extremity cellulitis, there was no documentation in the medical record describing the status of the infection. This lack of documentation persisted for 21 days after the resident's readmission to the facility, during which time staff did not record the condition of the wound, making it difficult to assess its progression or healing status. Interviews with the nursing staff revealed that they were aware of the infection but failed to document its status. RN 1 confirmed the absence of documentation, and RN 3 admitted to observing redness on the resident's left upper thigh but did not record it. During a dressing change, RN 2 and RN 3 could not confirm the exact location of the infection, indicating a lack of proper wound assessment and documentation. The facility's policy required weekly documentation of wound assessments, including location, description, and progress towards healing, which was not followed in this case.
Failure to Perform and Document PROM Exercises
Penalty
Summary
The facility failed to provide Passive Range of Motion (PROM) exercises to a resident as per the active orders. The resident, who had no cognitive impairment or memory issues, reported that staff did not regularly perform PROM exercises on his legs and could not recall the last time they were done. The active orders specified that PROM should be performed on both lower extremities every shift to prevent further contractures. However, a review of the resident's Work List Task History revealed that PROM was not charted as performed during the day shift on multiple dates, indicating non-compliance with the active orders. During an interview, the Nursing Manager confirmed that the PROM exercises were not documented as performed during the day shift on several dates. The facility's policy and procedure for Restorative Nursing Care required that exercises be individualized, planned, monitored, evaluated, and documented in the resident's medical record. The failure to document and potentially perform the PROM exercises as ordered had the potential to negatively impact the resident's mobility and functional status.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with five medication errors observed out of fifty-five opportunities, resulting in an error rate of 9%. One incident involved RN 11 administering Metformin 850 mg to a resident without food, despite the manufacturer's recommendation to take it with food to reduce the risk of stomach upset. The resident had not had breakfast, and RN 11 acknowledged forgetting the guideline during an interview. Another incident involved RN 11 administering three different eye drops to the same resident without following proper technique, including avoiding contact between the bottle tip and the patient's eyelashes and compressing the inner eye area after drop instillation. RN 11 admitted to being unaware of the proper technique guidelines during an interview. Additionally, LVN 4 administered Saline Nasal Spray to another resident without following the facility's nasal spray administration policy. The policy required advising the resident to simultaneously squeeze the lower portion of the bottle, continue sniffing 3-4 times, and avoid blowing their nose for at least two minutes. LVN 4 did not follow these instructions and admitted to being unaware of the proper technique required by the facility policy during an interview.
Failure to Monitor and Document Medication Storage Temperatures
Penalty
Summary
The facility failed to respond to refrigerated temperature excursions for medications when the continuous temperature monitoring system Temptrak alarmed. There was no evidence of a response in accordance with facility policy. Specifically, the pharmacy did not document follow-up actions for several instances where storage temperatures deviated outside the acceptable range, triggering temperature excursion alarms during November. The temperature log failed to provide details on any corrective actions undertaken in response to the alarm events on 11/1/2023, 11/7/2023, and 11/10/2023 when temperatures reached 35.4 F, 35.8 F, and 35.3 F respectively. Additionally, there were multiple alarms identified in August and September with no documentation indicating that the pharmacy addressed these temperature excursions when the alarms went off. The Director of Pharmacy acknowledged the need for improvement in their system when the medication refrigerators trigger alarms and emphasized the importance of proper documentation and follow-up to ensure that temperature excursions do not compromise the stability of medications. The facility also failed to monitor the temperature of the medication room located in the Pavilion Mezzanine skill nursing area. During an observation and interview, the medication nurse stated that the medication in the refrigerator and in the medication room were monitored by Temptrak, but she could not locate the temperature sensor for monitoring the ambient room temperature of the medication room. The Facility Engineer confirmed that there was no sensor installed in that medication room. The facility's policy and procedure indicated that all medication rooms should be part of the wireless temperature monitoring system, but this was not adhered to in this instance. These failures could have resulted in medications not being stored in accordance with manufacturers' recommendations, potentially compromising medication stability, potency, and patient safety. The lack of adherence to the facility's updated policy on temperature logs and the absence of a temperature sensor in the medication room highlight significant gaps in the facility's protocol compliance.
Failure to Verify Vendor's Food Safety Corrective Actions
Penalty
Summary
The facility failed to ensure that ready-to-eat foods obtained from Vendor 1 met current standards for food safety. During an initial tour of the walk-in refrigerator, it was observed that there were more than 10 cases of ready-to-eat food from an outside vendor. The Director of Food Services (DFS) stated that these items were used in various settings, including the resident units' pantry and the cafe. The DFS mentioned that a Registered Dietitian had evaluated the vendor's food safety aspects 12-18 months ago, but no other inspections had been conducted since then. The DFS also noted that the vendor had submitted a food safety inspection as part of the contract implementation process. However, the facility had not followed up on the issues identified by the US Food and Drug Administration (FDA) during their inspection of the vendor's operations in April 2023, which listed four food safety concerns requiring attention. In an interview, the DFS explained that the facility's contracting process for food services included a request for pertinent certifications at the time of contract implementation and a yearly review called a Vendor Preference Request. This review monitored product quality, temperature at delivery, and cleanliness of the delivery vehicle. If issues were identified, they would be incorporated into the departmental performance improvement program and the vendor preference report. Despite these procedures, the facility had not requested additional information from the vendor regarding the identified food safety concerns as of the date of the report.
Failure to Document Influenza Immunization or Refusal
Penalty
Summary
The facility failed to follow its policy and procedure on influenza immunizations for Resident 1303. The medical record did not include documentation of influenza immunization information or the refusal of the vaccine. Resident 1303, who was readmitted with diagnoses including sepsis and multiple drug-resistant organism (MDRO) Carbapenem-resistant Enterobacterales (CRE), did not have any record of receiving information on the risks and benefits of the influenza vaccine or documentation of refusal. Despite Resident 1303 stating that the vaccine was offered and refused twice, there was no corresponding documentation in the medical record. During an interview, the Director of Infection Prevention confirmed the absence of documentation in Resident 1303's medical record regarding the vaccine administration or the reason for its omission. The facility's policy requires that the licensed nurse document the resident's vaccine administration and education in the electronic health record, and if the vaccine is not given, the reason must be documented. This failure resulted in an incomplete medical record that did not reflect Resident 1303's preferences or care needs.
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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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