Lighthouse Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2222 Santa Ana Blvd., Los Angeles, California 90059
- CMS Provider Number
- 056478
- Inspections on file
- 37
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lighthouse Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that multiple food items in the kitchen refrigerator were not labeled with required dates, and a can opener used for food preparation was heavily soiled with dried food debris and stains. The Dietary Supervisor confirmed that these practices did not follow facility policy for food labeling and equipment sanitation, potentially affecting 123 residents.
Two residents did not receive proper assistance with personal hygiene and grooming. One resident, dependent on staff for bathing and with an indwelling urinary catheter, received inadequate bed baths and only one documented shower, while another had long, dirty fingernails that had not been cleaned or trimmed as required. Staff interviews and documentation confirmed these lapses, which were not in accordance with facility policies for routine bathing and nail care.
Two residents with indwelling urinary catheters did not receive necessary care, as one had an unsecured catheter causing discomfort and risk of dislodgement, while another did not have documented daily catheter care, contrary to facility policy and standard practice.
Two residents experienced medication errors when staff failed to administer medications as ordered by physicians. In one case, an extended-release medication was crushed and given via g-tube due to a mismatch between the physician's order and pharmacy supply, which was not identified by nursing staff. In another case, metformin was nearly administered without food, contrary to the order. These errors resulted in a medication error rate above 5%, as required by regulations.
Licensed nursing staff repeatedly crushed and administered an extended-release (ER) tablet of isosorbide mononitrate via g-tube to a resident instead of the prescribed immediate-release (IR) form, due to a failure to identify a mismatch between the physician's order and the medication supplied by the pharmacy. The pharmacy only provided the ER form and did not communicate the unavailability of the IR form. Multiple nurses administered the incorrect medication form over a two-week period to a resident with complex medical needs, in violation of facility policy.
A resident with intact cognition and specific care preferences repeatedly requested female CNAs for shower assistance, but was assigned a male CNA on multiple occasions. The resident reported discomfort and loss of dignity, and staff interviews confirmed that the preference was known but not documented or communicated in staff assignments, resulting in the ongoing issue.
A resident with severe cognitive impairment and no family or friends involved in her care did not have a timely referral submitted for probate conservatorship after being determined unable to make medical decisions. The referral was delayed by three months, during which time the clinical IDT oversaw the resident's care instead of an appointed conservator, contrary to facility policy.
Two residents were administered psychotropic medications without proper informed consent procedures. One resident received an antipsychotic for hiccups without documented education on risks and benefits, while another resident's consent for two antipsychotic medications was not renewed as required every six months. Staff confirmed these lapses, which were not in line with regulatory and facility policy requirements.
Two residents with severe physical and cognitive impairments were found with their call lights out of reach, preventing them from requesting assistance. Staff interviews and facility policy confirmed that call lights should be accessible at all times, but observations showed the devices were on the floor and not within reach, despite regular room rounds intended to ensure safety and accessibility.
Surveyors found that MDS assessments for three residents were not accurately completed, including failures to document oxygen therapy, incorrect diagnoses such as Alzheimer's Disease, and unreported dental issues like missing teeth. These inaccuracies were confirmed by MDS nurses through interviews and record reviews.
Five residents did not have individualized care plans addressing their specific clinical needs, including use of anticonvulsant and antipsychotic medications, management of a wearable defibrillator, refusal of restorative therapy, and oral care for edentulism. Staff interviews confirmed that these omissions led to a lack of guidance and communication among care team members regarding necessary interventions and monitoring.
A resident with multiple diagnoses and impaired cognitive skills experienced an unwitnessed fall. Although the IDT recommended new interventions, such as bed rails, these were not added to the resident's care plan, and the long-term care plan was not updated to reflect changes after the fall.
A resident with severe cognitive and physical impairments, including epilepsy and dementia, did not have floor mats properly placed at the bedside as ordered by the physician and outlined in the care plan. Observations showed that one mat was under the bed instead of at the bedside, and staff confirmed this did not meet the requirements for fall prevention, resulting in a deficiency related to accident hazard prevention.
A resident with COPD and other health conditions was found using a nasal cannula and humidifier that had not been changed weekly as required, and an oxygen mask was not stored in a plastic bag when not in use. Staff confirmed that these actions did not follow facility policy for respiratory care equipment maintenance and storage.
Two residents did not receive medications as ordered by their physicians due to failures in pharmacy supply and nursing administration. One resident received an extended-release medication crushed and given via g-tube, despite the order for an immediate-release form, while another was nearly given metformin without food, contrary to the order. Both incidents occurred because staff did not verify medication forms or follow administration instructions as required by facility policy.
A resident with parkinsonism and upper extremity impairment did not consistently receive weighted utensils as ordered by the physician and outlined in the care plan. Despite the need for adaptive equipment to assist with self-feeding due to hand tremors, observations showed the resident was provided with a weighted fork but regular spoon and knife. Staff interviews and facility policy confirmed the requirement for all utensils to be weighted and the responsibility of the dietary department to provide them.
A CNA failed to use enhanced barrier precautions and did not perform hand hygiene while providing high-contact care to two residents, including one with a gastrostomy tube. Despite facility policies and physician orders requiring gown, gloves, and hand hygiene between resident care activities, the CNA was observed moving between residents without following these protocols, increasing the risk of infection transmission.
A resident with severe cognitive impairment, hemiplegia, and dependence on staff for care was found to have a non-functional call light system. Despite the care plan requiring the call light to be within reach and explained to the resident, multiple attempts to use the call light failed, and staff confirmed it was not working. This left the resident unable to request assistance or communicate needs, contrary to facility policy.
Nursing staff failed to follow physician orders and facility policies regarding the changing of a urinary catheter drainage bag and the replacement of an oxygen humidifier bottle for two residents with cognitive impairments. An RN did not interpret a physician order correctly, resulting in a catheter drainage bag not being changed as required, while an RN and an LVN did not know or follow the policy for weekly humidifier bottle changes, instead altering the date on the bottle. These actions placed residents at risk for infection, as confirmed by the facility's infection preventionist.
A resident with multiple medical conditions requiring partial to moderate assistance with ADLs was not consistently offered or provided showers or baths, as evidenced by gaps in documentation and staff interviews. Facility policy required daily offers of bathing and proper documentation of refusals, but records showed several days without evidence of bathing being offered or provided.
A resident with multiple medical conditions, including diabetes and cellulitis, repeatedly refused wound care treatments and showers/baths as ordered. Despite facility policy requiring notification, the PCP was not informed of these refusals, and documentation was lacking in the progress notes.
A resident with multiple health conditions and at risk for pressure ulcers did not have weekly skin assessments documented promptly. An LVN entered several weeks of skin check documentation retrospectively, relying on memory, rather than charting on the day of assessment. The DON confirmed that timely documentation was required by facility policy, and the delay created the potential for inaccurate information and delayed care.
A resident was fatally injured when a transportation vehicle, double parked in the street, was hit by a speeding car. The facility failed to provide a designated parking area for safe resident transfer and did not adequately train staff on transportation safety. Staff were unaware of the importance of ensuring vehicles were parked safely, contributing to the accident.
A resident was physically abused by another resident who used a wet floor sign cone as a weapon, resulting in a bruise and cut. The incident occurred after a disagreement, and the cone was left unattended, contributing to the altercation. The facility's policies on abuse prevention and safety were not upheld, as the unattended cone posed a safety risk.
A resident in an LTC facility was injured when another resident, agitated after a verbal altercation, used an unattended wet floor sign cone as a weapon. The injured resident, with intact cognitive skills, sustained a bruise and cut on the elbow. Housekeeping staff left cones unattended for extended periods, contrary to facility policy, creating a safety hazard.
A resident with depression and anxiety was not informed by facility staff about her lack of secondary insurance coverage, resulting in a medical bill for uncovered costs. Despite having the capacity to make decisions, the resident was not assisted in applying for secondary coverage. Interviews revealed that the facility failed to follow protocols for verifying and informing residents about their insurance coverage, leading to this deficiency.
A resident with diabetes experienced a blood sugar level of 55 mg/dL, but the facility failed to administer Glucagon and notify the physician as per orders. Later, the resident became nonresponsive, yet the physician was not promptly informed, leading to the resident's transfer to a hospital. These actions violated the facility's protocols for managing hypoglycemia and significant changes in condition.
A resident with hearing, visual, and speech disabilities experienced significant distress due to the facility's failure to provide effective communication aids or interpreter services, as required by policy. Despite the resident's family informing staff that ASL was the preferred communication method, the facility lacked trained staff and relied on ineffective hand gestures and written communication. This led to the resident's frustration, agitation, weight loss, and eventual transfer to a hospital.
The facility's Infection Preventionist (IP) did not complete the required ten hours of continuing education for 2023, as confirmed during an interview. The IP acknowledged the responsibility to stay updated on infection prevention and control practices. The Director of Nursing (DON) highlighted the importance of the IP being informed to educate staff effectively. This deficiency raised concerns about the IP's ability to stay current with infection control practices.
The facility failed to obtain informed consent for the use of physical restraints on several residents, including bedrails and lap trays, without informing the residents or their responsible parties of the risks and benefits. This deficiency was observed in multiple cases, where documentation and communication were lacking, violating the residents' rights to make informed decisions about their care.
The facility failed to ensure residents were free from physical restraints, as several residents had bedrails and beds placed against the wall without physician orders, care plans, or informed consent. Less restrictive measures were not implemented, and the IDT did not perform necessary assessments, leading to inappropriate restraint use.
The facility failed to maintain proper hygiene for four residents, including timely diaper changes and nail care. A resident developed a UTI due to infrequent diaper changes, while three others had long, dirty fingernails, increasing infection risk. Staff interviews confirmed lapses in care responsibilities.
The facility failed to assess the medical need, obtain physician orders, and secure informed consent for bed rail use for nine residents. Observations showed residents with bed rails up without documented assessments or orders. Interviews revealed that residents were unaware of the reason for siderails, and staff confirmed the lack of necessary assessments and consent, indicating a systemic issue in the facility's process.
The facility failed to follow food production recipes and fortified diet guidelines, affecting residents on fortified, pureed, and mechanical soft diets. Fortified diets were not served to 10 residents, pureed vegetables were improperly prepared for 17 residents, and incorrect portion sizes were given to those on mechanical soft diets. These deficiencies were confirmed by the dietary supervisor.
The facility failed to maintain safe food storage and preparation practices, with unlabeled thawing meat and a dirty ice machine. A dietary aide improperly sanitized a sink used for both raw meat and cooked vegetables. These practices risked cross-contamination and foodborne illness.
The facility failed to develop and update comprehensive care plans for 15 residents, leading to unmonitored medication use, unaddressed behaviors, and improper use of physical restraints and devices. This included the lack of care plans for psychotropic medications, wandering behaviors, and the use of dentures and bedrails, posing risks to resident safety and well-being.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential impacts on their care plans. One resident's MDS did not include hallucinations despite documented evidence, while another's omitted an anxiety disorder diagnosis. These inaccuracies were acknowledged by the DSS and DON, highlighting the importance of precise assessments for effective care planning.
The facility failed to ensure accurate PASRR assessments for two residents with schizophrenia and depression. One resident did not receive a required Level II Mental Health Evaluation due to a duplicate Level I Screening, while another had an inaccurate Level I Screening that omitted the need for further evaluation. These oversights potentially deprived the residents of necessary mental health services.
A resident developed a pressure ulcer while under the care of an LTC facility, despite being admitted without any skin breakdown. The resident required total assistance with daily activities and had constant fecal incontinence, but the care plan lacked specific interventions for increased incontinence care and moisture barrier creams. Staff interviews revealed inconsistencies in care plans and inadequate implementation of the facility's pressure ulcer management protocols.
Two residents were at risk of injury when maintenance tools and sharp objects were left unattended in their shared room. One resident, with dementia and other cognitive impairments, and another with multiple sclerosis, were both asleep when the tools were left by a maintenance assistant. Facility staff confirmed that leaving tools unattended is against policy due to safety concerns.
A resident with a history of muscle weakness and dysphagia experienced significant weight loss due to the facility's failure to implement the RD's recommendation for an RNA feeding program. Staff were unaware of the recommendation, and the resident continued to feed himself without supervision, increasing the risk of further weight loss.
A resident with deafness and visual impairment was administered lorazepam for anxiety without prior non-pharmacological interventions or effective communication methods. The facility did not utilize the resident's preferred communication method, such as ASL, leading to frustration and agitation. Staff were aware of the communication barriers but lacked interpreter services, resulting in potentially inaccurate assessments and unnecessary medication.
A facility failed to store Gabapentin solution as per manufacturer's requirements, keeping it at room temperature instead of refrigerated. An LVN noted the medication was not returned to the fridge after each dose, risking its effectiveness for a resident needing it for nerve pain.
A resident was served a meal containing beef despite having expressed a dislike for it, leading to the resident not eating the provided lunch. The Dietary Supervisor confirmed the oversight despite multiple checks in place, and the DON highlighted the importance of honoring food preferences to prevent malnutrition. Facility policy mandates substitutes for disliked foods, which was not followed in this instance.
A resident with severe cognitive impairment and high fall risk was allowed to walk independently despite needing moderate assistance, resulting in a fall and hip fracture. Communication gaps between the rehabilitation and nursing staff contributed to the lack of supervision, as the resident often walked alone without assistive devices. The facility's fall prevention policy was not effectively implemented, leading to the incident.
The facility failed to accurately monitor orthostatic blood pressure for two residents, leading to potential risks of delayed medical intervention. The blood pressure readings were not taken in the correct sequence or with appropriate timing, as required by the facility's policy. Interviews with staff confirmed the improper procedure and documentation, which could prevent accurate assessment of the residents' conditions.
A resident with muscle weakness and gait abnormalities required a two-staff assist for turning and repositioning, as per their care plan. However, CNAs documented using only one staff member, unaware of the requirement due to ineffective communication from LVNs or RNs. This failure to follow the care plan posed a potential risk to the resident's safety.
The facility staff failed to notify the physician of behavior changes for a resident with a history of aggressive behavior, leading to an incident where the resident attacked another resident. Despite being on close monitoring, the resident was taken off monitoring without proper documentation or physician notification, resulting in harm to another resident.
The facility failed to report a resident-to-resident altercation to the State Survey Agency within the required 2-hour timeframe. A resident with severe cognitive impairment was attacked by another resident with schizophrenia and homicidal ideations. The initial report fax did not go through, and the report was only successfully sent four days later. This delay was confirmed by staff interviews and the facility's policy on abuse reporting.
Deficient Food Storage and Equipment Sanitation in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure safe and sanitary food storage and equipment maintenance practices in the kitchen, affecting 123 out of 125 residents. During an initial kitchen tour, multiple food items—including margarine, whipped cream, chocolate syrup, dairy creamer, and parmesan cheese—were found in the refrigerator without any labels indicating the date they were opened or the date by which they should be used. The Dietary Supervisor confirmed that facility policy requires food items to be labeled with received, opened, and expiration dates, and acknowledged that unlabeled food could not be verified as safe for consumption. The supervisor also stated that refrigerators are checked daily to ensure proper labeling and to identify expired items. Additionally, the can opener attached to the food preparation table was found to be in an unsanitary condition, with blackened surfaces, black stains, and dried, hardened food debris around the blade and gear. The Dietary Supervisor confirmed that the can opener should be kept clean and sanitary to prevent contamination and bacterial growth, as outlined in facility policy and the 2017 Food Code. These observations were corroborated by interviews and a review of facility policies, which require thorough cleaning of the can opener each work shift and proper labeling and dating of all food items.
Failure to Provide Adequate Bathing and Nail Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for two residents, resulting in deficiencies related to personal hygiene and grooming. One resident, who had chronic obstructive pulmonary disease, generalized muscle weakness, neuromuscular bladder dysfunction, and an indwelling urinary catheter, was dependent on staff for bathing and other ADLs. Despite care plans and staff expectations for regular showers or bed baths, the resident reported only receiving two showers and described bed baths as inadequate, with CNAs using only lightly wetted washcloths and not following proper procedures. Documentation in the electronic health record confirmed only one shower was recorded, and staff interviews acknowledged the lack of proper bathing and documentation, which was essential for cleanliness and infection prevention, especially given the resident's catheter use. Another resident, with diagnoses including schizophrenia and muscle weakness, required moderate assistance with ADLs and had intact cognition. Observations revealed this resident had visibly long, irregular fingernails with dark brown debris underneath, which curled over the fingertips. The resident stated that nail care had not been provided for some time. Staff confirmed that nail care, including cleaning and trimming, was their responsibility and should be performed daily to maintain hygiene and prevent potential health issues. The DON also stated that dirty fingernails were unacceptable and increased the risk of infection, particularly when residents handled food or shared items. Facility policies reviewed indicated that showers and nail care were to be provided routinely to ensure cleanliness, comfort, and prevention of body odors and infection. However, the observed and documented failures to provide these services as required led to deficiencies in maintaining good grooming and personal hygiene for the two residents involved.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
Two residents with indwelling urinary catheters did not receive appropriate care as required by facility policy and standards. One resident, who had chronic obstructive pulmonary disease, generalized muscle weakness, and neuromuscular bladder dysfunction, was found with an unsecured urinary catheter. The resident reported discomfort and the sensation of the tubing pulling or poking, and both a treatment nurse and the Director of Nursing confirmed that the catheter should have been secured to prevent accidental pulling, dislodgement, and unnecessary pressure. Another resident, with diagnoses including urinary retention, gastrostomy status, severe sepsis with septic shock, and paranoid schizophrenia, did not receive documented daily urinary catheter care. The resident was entirely dependent on staff for activities of daily living and had a physician's order for a urinary catheter. Review of the treatment administration record and physician's orders revealed no documentation of daily catheter care since the catheter was placed. The treatment nurse confirmed that daily catheter care was the facility's standard practice to prevent infection and that documentation was necessary to verify care was provided. Facility policy required that catheters be anchored with a leg strap to prevent tension and potential injury, and that daily catheter care be documented in the medical record. Both residents did not receive care in accordance with these policies, as one had an unsecured catheter and the other lacked documentation and evidence of daily catheter care.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Order Discrepancies
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with two errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. One resident, who had significant medical conditions including hemiplegia, hemiparesis, dementia, dysphagia, and a gastrostomy tube, was prescribed isosorbide mononitrate 30 mg to be administered via g-tube. However, the pharmacy supplied only the extended-release (ER) form of the medication, which was not intended to be crushed or administered via g-tube unless specifically ordered. Nursing staff failed to notice the discrepancy between the physician's order and the medication label, and proceeded to crush and administer the ER tablets via g-tube on multiple occasions. Both the pharmacy and nursing staff did not communicate or clarify the order, and the error persisted over several administrations. Another resident, with diagnoses including diabetes mellitus, gastrointestinal hemorrhage, and schizoaffective disorder, was prescribed metformin 1000 mg to be given with food or a meal. During medication administration, the nurse attempted to give the metformin without ensuring the resident had food, contrary to the physician's order. The nurse acknowledged the error and recognized that the medication should have been administered with food to align with the order and prevent potential gastric upset. The facility's policy required licensed nurses to perform three checks—comparing the physician's order, pharmacy label, and medication administration record—prior to administering medications, and to resolve any discrepancies before proceeding. In both cases, the required checks were not properly performed, and medications were administered in a manner inconsistent with physician orders, directly contributing to the identified medication errors.
Significant Medication Error: Incorrect Form of Isosorbide Mononitrate Administered
Penalty
Summary
Licensed nursing staff failed to ensure a resident was free from significant medication errors when they administered the incorrect form of isosorbide mononitrate. The staff crushed and administered an extended-release (ER) tablet of isosorbide mononitrate 30 mg via g-tube instead of the prescribed immediate-release (IR) form on 14 occasions. This error occurred over a two-week period and was not identified by the nursing staff during medication administration, despite the facility's policy requiring comparison of the physician's order, pharmacy label, and medication administration record. The resident involved had multiple complex medical conditions, including hemiplegia, hemiparesis following cerebral infarction, dementia, dysphagia, schizophrenia, and a gastrostomy tube. The resident was entirely dependent on staff for activities of daily living and had severely impaired cognitive skills. The medication order specified isosorbide mononitrate 30 mg via g-tube daily for hypertensive heart disease, but only the ER form was supplied and administered. Both the pharmacy and nursing staff failed to recognize the discrepancy between the physician's order and the medication supplied. The pharmacy delivered only the ER form, stating the IR form was not available, and did not communicate this to the facility. Nursing staff did not clarify the order with the physician or pharmacy, and multiple nurses administered the ER medication in crushed form, contrary to standard practice and facility policy. The Director of Nursing confirmed that these actions did not follow expected procedures and placed the resident at risk.
Failure to Honor Resident's Shower Care Preferences and Dignity
Penalty
Summary
The facility failed to honor a resident's expressed preference for female CNAs to assist with showers, resulting in repeated assignments of a male CNA despite the resident's clear and ongoing requests. The resident, who had intact cognition and required supervision or touching assistance for activities of daily living, reported feeling uncomfortable, embarrassed, and experiencing a loss of dignity due to the facility's disregard for her wishes. The resident's preference was communicated multiple times to staff, yet male CNAs continued to be assigned to her on scheduled shower days. Interviews and record reviews revealed that the Director of Staff Development (DSD) was aware of the resident's preference but failed to document or communicate this requirement in the daily staff assignment sheets, leading to the oversight. The male CNA assigned was not informed of the resident's preference, and the Director of Nursing (DON) acknowledged that such preferences should be honored and clearly communicated. Facility policies reviewed indicated a commitment to resident privacy, dignity, and respect, but these were not upheld in this instance.
Delayed Referral for Probate Conservatorship for Resident Lacking Capacity
Penalty
Summary
The facility failed to timely submit a referral for probate conservatorship for a resident who lacked decision-making capacity and had no family or friends involved in her care. The resident, who had diagnoses including encephalopathy, cerebral infarction, and schizophrenia, was assessed as severely cognitively impaired and dependent on staff for daily activities. Despite being determined by her physician as unable to make medical decisions in November 2024, the referral for conservatorship was not made until three months later, after an Interdisciplinary Team (IDT) meeting. During this delay, the clinical IDT was responsible for overseeing the resident's care, as there was no appointed conservator or surrogate decision-maker. Both the Social Services Director and the Director of Nursing acknowledged that the referral process should have been initiated immediately upon determining the resident's incapacity and lack of involved family or friends. The facility's policy required prompt appointment of a personal representative for residents lacking decision-making capacity and without a surrogate, but this was not followed in a timely manner for this resident.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for two residents. For one resident with diagnoses including schizophrenia and major depressive disorder, the clinical record showed that Chlorpromazine, an antipsychotic medication, was prescribed and administered via gastrostomy tube for hiccups. However, there was no documentation that the resident received education regarding the risks and benefits of Chlorpromazine prior to its initiation. The Director of Nursing confirmed that informed consent was not obtained for this medication, despite its classification as a psychotropic drug. For another resident with diagnoses including schizophrenia and metabolic encephalopathy, the facility did not ensure that informed consent for the use of Risperidone and Seroquel, both antipsychotic medications, was renewed every six months as required. The resident's cognition was intact, and the medications were prescribed for symptoms such as verbal aggression, angry outbursts, and auditory hallucinations. Review of the medical record revealed that the most recent informed consent form for these medications was outdated and had not been renewed within the required timeframe. A registered nurse acknowledged that the consents should have been updated to ensure the resident remained informed about the continued use, risks, and benefits of the medications. The facility's failure to obtain and renew informed consent for psychotropic medications was contrary to both state regulatory requirements and the facility's own policy. The deficiency was identified through interviews, record reviews, and reference to relevant All Facilities Letters and facility policies, which specify the need for written informed consent and regular renewal for psychotherapeutic drug use.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for two residents, both of whom had significant physical and cognitive impairments. For one resident with generalized muscle weakness, hemiplegia following a cerebral infarction, and severe cognitive impairment, observations on two separate occasions found the call light on the ground behind the head of the bed, tangled in the bed frame and not accessible to the resident. This resident was dependent on staff for dressing and required partial assistance for bed mobility. Another resident, admitted with hemiplegia, dysphagia, schizophrenia, and diabetes mellitus, was also found to have the call light on the floor behind the bed and not within reach. This resident was totally dependent on staff for activities of daily living and had a care plan indicating the call light should be within reach due to a high risk for falls and injuries. Staff interviews confirmed that call light placement is part of routine room rounds and that the call light should be within reach for resident safety and communication. Facility policy and procedure required that all residents be provided with a call system to alert nursing staff, with call cords placed within reach. Staff interviews acknowledged the importance of call light accessibility and confirmed that both licensed and unlicensed staff are responsible for ensuring call lights are within reach during rounds. The failure to keep the call lights accessible removed the residents' ability to request assistance and was identified through direct observation and staff interviews.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for three residents accurately reflected the care and services they received. For one resident with dementia and epilepsy, the MDS did not indicate the use of oxygen therapy, despite physician orders and vital sign flowsheets confirming ongoing oxygen therapy. The MDS nurse acknowledged that the assessment was inaccurate and emphasized the importance of correct coding, especially for interventions requiring special precautions such as oxygen therapy. Another resident, admitted with schizophrenia and major depressive disorder, was incorrectly coded on the MDS as having Alzheimer's Disease, despite no medical diagnosis or cognitive impairment documented in the medical record. The MDS nurse confirmed that this error could lead to unnecessary treatments or medications for conditions the resident did not have. The MDS was supposed to be based on hospital paperwork and resident interviews, but the diagnosis was inaccurately entered. A third resident, diagnosed with malignant neoplasm of the liver and schizophrenia, was assessed on the MDS as not having any oral or dental issues. However, direct observation and resident interview revealed that the resident had no natural teeth and did not have dentures, relying on soft foods. The MDS nurse confirmed awareness of the resident's dental status and acknowledged the MDS was coded incorrectly. Facility policy required that all MDS sections accurately reflect the resident's status at the time of assessment, which was not followed in these cases.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, each with specific clinical needs that required individualized interventions. For one resident prescribed valproic acid for schizoaffective disorder and behavioral outbursts, the care plan did not address the use of this medication, omitting guidance for staff on monitoring, assessment, and management of potential side effects. Interviews with the MDS nurse and DON confirmed that the absence of a care plan for this medication could leave staff uninformed about necessary care and monitoring. Another resident was observed wearing an external heart defibrillator vest, but there was no care plan outlining interventions for the care, monitoring, or maintenance of the device. The RN and DON both acknowledged the importance of having a care plan to ensure staff understood the device's operation and maintenance requirements. The lack of such a plan meant that staff did not have clear instructions for managing the resident's cardiac device. Additional deficiencies included the absence of a care plan for a resident who refused restorative nurse aid services despite being dependent for mobility and ADLs, with no interventions documented to address the refusals or prevent functional decline. One resident with no natural teeth did not have a care plan addressing their edentulous status or oral care needs, and another resident receiving chlorpromazine via G-tube for hiccups had no care plan to monitor for side effects or guide care. In each case, staff interviews confirmed that the lack of individualized care plans resulted in insufficient communication and guidance for providing appropriate care.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan and interventions for a resident after the resident experienced an unwitnessed fall. The resident, who had diagnoses including parkinsonism, schizoaffective disorder, and major depressive disorder, was assessed as having moderately impaired cognitive skills and was dependent on staff for activities of daily living. Following the fall, the Interdisciplinary Team (IDT) met and recommended new interventions, such as the use of bed rails for safe bed mobility, but these interventions were not incorporated into the resident's care plan. Interviews with facility staff, including the MDS nurse, QA nurse, and DON, confirmed that although a short-term care plan was developed and the IDT recommended additional interventions, the long-term care plan was not updated to reflect these changes. The facility's policy required the care plan to be reviewed and updated after significant events such as falls, but this was not done in this case, resulting in a failure to communicate new interventions to staff responsible for the resident's care.
Failure to Ensure Proper Placement of Fall Mats for High-Risk Resident
Penalty
Summary
The facility failed to ensure that floor mats, intended to prevent injury from falls, were properly placed at the bedside for one resident with significant fall risk. The resident in question had diagnoses of epilepsy and dementia, with severely impaired cognition and physical limitations affecting both upper and lower extremities. According to the resident's physician order and care plan, floor mats were to be placed at the bedside and checked every shift due to behaviors such as rolling out of bed or placing herself on the floor. However, during multiple observations, only one mat was found at the bedside while the other was under the bed and not accessible for fall protection. Interviews with nursing staff confirmed that the floor mats were not positioned as required by the physician's order and care plan. The staff acknowledged that the improper placement of the mats would not prevent injury if the resident were to fall. The facility's policy on fall prevention required individualized care planning and implementation of interventions based on identified risk factors, but these were not followed in this instance, resulting in a deficiency related to accident hazard prevention and supervision.
Failure to Change and Store Oxygen Equipment per Policy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not adhering to its own policy regarding the maintenance and storage of oxygen delivery equipment. Specifically, a resident with chronic obstructive pulmonary disease (COPD), generalized muscle weakness, and neuromuscular dysfunction of the bladder was observed using a nasal cannula and humidifier that had not been changed for over a week, as indicated by the date on the equipment. Additionally, the resident's oxygen mask was found hanging from the bed and nightstand, not stored in a plastic bag as required, and at one point was almost touching the floor. The resident reported that the nasal cannula and humidifier were only changed when the humidifier bottle was empty, rather than on a weekly basis as per facility policy. Interviews with nursing staff and the Infection Preventionist Nurse confirmed that the facility's policy required weekly changes of all oxygen tubing, humidifiers, masks, and cannulas, and that unused oxygen masks should be stored in a plastic bag to prevent contamination. The staff acknowledged that the equipment had been in use longer than permitted and that proper storage procedures were not followed. Review of the facility's policy further supported these requirements, indicating that the observed practices were not in compliance.
Failure to Provide Pharmaceutical Services and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services and routine medications as ordered for two residents. For one resident with a history of hemiplegia, hemiparesis, cerebral infarction, dementia, dysphagia, schizophrenia, and a gastrostomy, the physician ordered isosorbide mononitrate 30 mg oral tablet to be administered via g-tube once daily. However, the pharmacy supplied only the extended-release (ER) form of the medication, which is not intended to be crushed or administered via g-tube unless specifically prescribed. Nursing staff did not notice the discrepancy between the physician's order and the medication label, and proceeded to crush and administer the ER tablets via g-tube on multiple occasions. Both the pharmacy and nursing staff failed to clarify the order or communicate the unavailability of the immediate-release form, resulting in the resident receiving the medication in a manner not consistent with the physician's order. Another resident, with diagnoses including diabetes mellitus, gastrointestinal hemorrhage, and schizoaffective disorder, was ordered metformin 1000 mg to be given once daily with food or a meal. During medication administration, a nurse attempted to give the metformin without ensuring the resident had food, contrary to the physician's order. The nurse acknowledged that the medication should have been administered with food and that failing to do so did not align with the order. The facility's policy and procedure for medication administration required licensed nurses to administer medications per the physician's order, perform three checks (comparing the physician's order, pharmacy label, and medication administration record), and resolve any discrepancies before administration. In both cases, these procedures were not followed, resulting in medications being administered in a manner inconsistent with physician orders.
Failure to Provide Ordered Weighted Utensils for Resident with Hand Tremors
Penalty
Summary
The facility failed to provide a resident with weighted utensils as ordered by the physician and outlined in the resident's care plan. The resident, who had diagnoses including parkinsonism, schizoaffective disorder, and major depressive disorder, was noted to have hand tremors and impaired upper extremity function, making self-feeding difficult. The resident's care plan and physician orders specifically required the use of adaptive feeding equipment, including a divided plate and weighted utensils, to support independence in eating. Observations on two separate occasions revealed that the resident received a weighted fork but was given a regular spoon and knife, despite the order for all utensils to be weighted. During these observations, the resident exhibited hand shaking while attempting to use the regular spoon, which made self-feeding challenging. Interviews with the Director of Rehab confirmed that the resident required weighted utensils to stabilize her hand and facilitate self-feeding, and that failure to provide these could result in the resident dropping food and becoming discouraged. The Dietary Supervisor acknowledged that the kitchen was responsible for providing the correct adaptive equipment as per physician orders and that the resident should have received weighted utensils for all meals. Review of facility policy confirmed that adaptive equipment is to be provided when recommended and that the dietary department is responsible for ensuring the correct equipment is distributed with meal trays.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Certified Nursing Assistant (CNA) 5 failed to implement required infection control measures for two residents during direct care activities. Specifically, CNA 5 did not use enhanced barrier precautions (EBP), such as wearing a gown and gloves, while providing high-contact care to a resident with a gastrostomy tube, as ordered by the physician and outlined in the resident's care plan. Additionally, CNA 5 did not perform hand hygiene between caring for two different residents or after removing gloves, despite facility policy and training indicating this as a critical step to prevent infection transmission. Resident 13 had diagnoses including generalized muscle weakness and dementia, with severely impaired cognition and dependence on staff for personal hygiene and bed mobility. Resident 78, who also had severely impaired cognition and was dependent on staff for personal hygiene and dressing, had a gastrostomy tube and was under physician orders and a care plan requiring EBP. During observations, CNA 5 was seen assisting Resident 78 with activities of daily living and then immediately providing care to Resident 13 without changing gloves, donning a gown, or performing hand hygiene between residents. Interviews with CNA 5 and the Infection Preventionist Nurse confirmed that staff were aware of the requirements for hand hygiene and EBP, and that failure to follow these protocols could lead to the spread of infection. Review of facility policies further supported that EBP and hand hygiene were required during high-contact care and between resident interactions. The observed lapses in infection control practices placed the residents at risk for infection and illness.
Non-Functional Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, generalized muscle weakness, dysphagia, and severely impaired cognition was found to have a non-functional call light system. The resident was dependent on staff for personal hygiene and required significant assistance for repositioning in bed. The care plan for this resident specified that the call light should be within reach and that staff should explain its use for requesting assistance. However, during multiple observations, the resident pressed the call light several times, but the indicator light outside the room did not activate, confirming the system was not working. Interviews with facility staff, including a CNA and an RN, confirmed that the call light was not functional and that it should always be operational to allow residents to request help. The facility's policy required a mechanism for residents to promptly communicate with nursing staff, but this was not provided in this instance. As a result, the resident was unable to call for staff assistance or express needs, placing him at risk for delayed care or accidents.
Failure to Ensure Nursing Staff Competency in Infection Control Procedures
Penalty
Summary
Registered Nurse (RN) 1 failed to correctly interpret and carry out a physician's order regarding the frequency of changing a resident's urinary catheter drainage bag. The order specified that the drainage bag should be changed every two weeks and as needed, but RN 1 initially believed the order was to change the bag only if needed every two weeks. This misunderstanding led to the drainage bag not being changed at the required intervals, contrary to the resident's care plan and physician's order. The Director of Nursing (DON) confirmed that the order was clear and that licensed nursing staff should have the competency to interpret and implement such orders. The Infection Preventionist Nurse (IPN) stated that not changing the drainage bag as ordered could harbor bacteria and lead to infection. In a separate incident, RN 2 and Licensed Vocational Nurse (LVN) 4 did not demonstrate knowledge of the facility's policy and procedure for replacing a resident's oxygen humidifier bottle. Observations revealed that a resident's humidifier bottle was not changed weekly as required by facility policy, and the date on the bottle had been altered rather than the bottle being replaced. LVN 4 admitted to not knowing the correct frequency for changing the humidifier bottle and stated she was following guidance from RN 2, who also did not follow the facility's policy. The DON and IPN confirmed that the policy required weekly changes for infection control purposes. Both incidents involved residents with significant cognitive impairments and dependence on staff for care. The failures by nursing staff to follow physician orders and facility policies placed residents at risk for infection and illness, as confirmed by the facility's infection preventionist and documented in the residents' care plans and medical records.
Failure to Consistently Offer and Document Bathing Assistance for Resident Requiring ADL Support
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living (ADLs), specifically bathing and showering, was consistently offered and provided these services. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was assessed as having no cognitive impairment and required partial to moderate assistance with bathing and personal hygiene. Observations noted the resident with oily, unwashed hair, and interviews with staff confirmed that showers should be offered daily, with refusals documented and reported to the charge nurse. However, a review of the resident's ADL documentation revealed multiple dates in April where there was no record of the resident being offered or receiving a shower or bath. Staff interviews further confirmed the expectation that residents be offered showers daily and that refusals be properly documented. The Director of Staff Development acknowledged the lack of documentation for several days, and the Director of Nursing reiterated the facility's policy that residents should be offered showers or baths daily. The facility's policy also stated that residents are to be offered a shower at least once weekly and as requested. The absence of documentation and failure to offer or provide bathing assistance as required led to the deficiency.
Failure to Notify PCP of Resident's Refusals of Care and Treatment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not notifying the resident's Primary Care Provider (PCP) of repeated refusals of showers/baths and wound care treatment. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was assessed as having no cognitive impairment and was able to make decisions. Physician orders were in place for daily moisturizing ointment to the feet and specific wound care for cellulitis on the right lower leg. Documentation showed that the resident refused wound care on multiple occasions and refused showers/baths on several dates. Despite these refusals, there was no evidence in the progress notes that the PCP was notified of the missed wound care treatments or showers/baths. Interviews with facility staff, including a CNA, LVN, DSD, and DON, confirmed that the facility's policy required notification of the PCP and documentation of refusals, but this was not done. The facility's policies on care and wound management also specified that the physician and interdisciplinary team should be informed of such refusals, which did not occur in this case.
Failure to Timely Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin checks were documented in a timely manner for one resident. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was at risk for developing pressure ulcers and required partial to moderate assistance with activities of daily living. Although weekly skin assessments were indicated as performed on specific dates, the documentation for these assessments was not created until several weeks later, based on the nurse's recollection rather than contemporaneous observation. During interviews, the LVN acknowledged that the documentation for multiple weekly skin checks was entered retrospectively, relying on memory rather than immediate charting. The Director of Nursing confirmed that skin assessments should be documented on the same day to ensure accuracy and admitted there was potential for inaccuracy in the records. Facility policies required that resident health records be current, accurate, and timely, and that licensed nurses document weekly skin assessments and the effectiveness of treatments. The failure to document skin checks promptly resulted in the potential for inaccurate information to be communicated among healthcare providers and could delay necessary care or interventions.
Failure to Ensure Safe Resident Transportation Leads to Fatal Accident
Penalty
Summary
The facility failed to ensure a safe transfer for a resident to a medical appointment, resulting in a tragic accident. The transportation vehicle was double parked in the middle of the street instead of a designated parking space, which led to the vehicle being hit by a speeding car. The resident, who was strapped in a wheelchair in the back of the van, sustained life-threatening injuries and was later pronounced dead at the hospital. The facility did not provide adequate training to staff on safe transportation practices. Interviews with staff members revealed that they were not in-serviced on transportation safety, and there was no system in place to identify potential safety risks or unsafe work practices. Staff members were unaware of the importance of ensuring that transportation vehicles were parked safely before transferring residents. The facility's policies and procedures regarding accidents and incidents, as well as the safety committee's duties, were not followed. The facility did not have a designated area for loading and unloading residents, and staff parking occupied available street parking, forcing transportation vehicles to double park. This lack of compliance with safety protocols and inadequate staff training contributed to the accident that resulted in the resident's death.
Removal Plan
- Social Services Staff sent a written notice to all outside transportation providers to inform them of the accident and to remind transportation companies that provide service to this facility to never double-park or park in the flow of traffic lanes while loading and unloading residents and staff in front of the facility and that they are required to comply with all applicable traffic laws and best practices to ensure the safety and well-being for all parties.
- The ADM checked to ensure that signs were posted to designate a space for loading and unloading residents from transportation vehicles, located in the parking lot closest to the entrance to the facility.
- The Director of Staff Development (DSD) in-serviced licensed nurses, Certified Nursing Assistants (CNAs), and front Lobby staff to ask drivers upon entry to the facility as to where they are parked to ensure that residents are transferred onto vehicles that are parked safely and not double-parked in the flow of traffic.
- All staff in the facility were in-serviced by the DSD/ RN Supervisor/ ADM regarding transportation safety with emphasis upon: The incident / accident that occurred, Importance of informing transportation services to use only designated parking space when transferring residents to/ from the facility, Ensure there will be no double parking in front of the facility while loading and unloading residents, Ensure the transportation vehicle must park at the marked loading area at all times, Ensure Residents are transported / escorted to and from the facility in a safe manner, The importance of reporting any safety hazards or unsafe work practices having potential for possible harm or danger to Residents [i.e. double-parked transportation vehicles] to the RN Supervisor and/or ADM to ensure timely corrective action, Instruct staff to not park in areas designated for transportation services.
- The RN Supervisor will report any unwanted findings to the facility ADM during daily stand-up meetings to ensure timely corrective action and implementation into the Safety Committee for systemic review and additional corrective action.
- The Quality Assurance and Performance Improvement (QAPI) nurse and facility ADM will develop a Performance Improvement Plan and report the findings to the QAPI committee on a monthly basis for 3 months to monitor and ensure the effectiveness of the corrective action and systemic changes.
Resident-to-Resident Physical Abuse Due to Unattended Safety Equipment
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident was hit by another with a wet floor sign cone. The affected resident, who had intact cognitive skills and required supervision for activities of daily living, sustained a bruise and cut on the right elbow. The incident occurred after the resident asked their roommate to stop an unpleasant behavior, leading to the roommate becoming upset and using the wet floor sign cone as a weapon. The roommate had moderately impaired cognitive skills and was independent in activities of daily living. The incident was witnessed by a registered nurse who heard yelling and observed the agitated resident holding the wet floor sign cone. The nurse confirmed that the wet floor sign cone was left unattended in front of the residents' room, which contributed to the incident. The facility's policy on patient abuse and mistreatment, as well as the policy on the safety of residents, indicated that residents should be free from physical abuse and provided with a safe environment. However, the unattended placement of the wet floor sign cone posed a safety risk, leading to the physical altercation between the residents.
Unattended Housekeeping Cones Lead to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for residents by leaving housekeeping cones, specifically wet floor sign cones, unattended in residents' rooms. This oversight led to an incident where one resident was hit by another resident with a wet floor sign cone, resulting in a bruise and cut on the right elbow of the affected resident. The incident occurred after a verbal altercation between the two residents, where one became agitated and used the unattended cone as a weapon. The affected resident, who was cognitively intact and required supervision for activities of daily living, was admitted with diagnoses including diabetes, schizophrenia, major depression, and hypertension. The resident reported feeling threatened and scared after being hit by the roommate, who had moderate cognitive impairment and was independent in daily activities. The roommate, diagnosed with schizophrenia, anxiety, and hypertension, was observed by a registered nurse to be agitated and holding the wet floor sign cone during the incident. Housekeeping staff admitted to leaving wet floor sign cones unattended for 10 to 20 minutes while cleaning multiple rooms, citing time constraints as a reason for not staying until the floors were dry. The facility's policies and procedures required housekeeping staff to keep cleaning equipment out of residents' way, but this was not adhered to, leading to the safety hazard. The facility's safety committee was responsible for overseeing safety practices, but the unattended cones posed a risk to residents' safety, as confirmed by staff observations.
Failure to Inform Resident of Insurance Coverage
Penalty
Summary
The facility staff failed to inform a resident about her medical coverage during her stay, resulting in a deficiency. The resident, who had diagnoses of depression and anxiety disorder, was admitted to the facility with intact cognitive skills and the capacity to make decisions. However, the facility did not inform her that she lacked secondary insurance coverage, which would cover costs not paid by her primary insurance. This oversight led to the resident receiving a medical bill for the uncovered amount. The facility's electronic medical records lacked documentation indicating that the resident was informed about her lack of secondary coverage. Interviews with the Business Office Manager (BOM) and the Director of Nursing (DON) revealed that the facility's protocol required staff to verify and inform residents about their insurance coverage upon admission and assist them in applying for secondary coverage if needed. However, the BOM admitted that there was no conversation or documentation regarding the resident's lack of secondary coverage, and the DON confirmed that it was the staff's responsibility to assist residents with applying for Medicare services. The resident expressed that she was unaware of her lack of secondary coverage and would have chosen not to stay at the facility had she been informed. She expected the facility staff to inform her of her medical benefits and assist with any issues, but this did not occur. The BOM and DON acknowledged the importance of informing residents about their insurance status to prevent issues with continuous care and financial responsibility for uncovered portions of care.
Failure to Administer Glucagon and Notify Physician for Low Blood Sugar
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with diabetes, as evidenced by several lapses in following professional standards of practice. The resident, who was on multiple medications to lower blood sugar levels, had a blood sugar reading of 55 mg/dL, which is below the normal range. Despite the physician's order to administer Glucagon 1 mg intramuscularly and notify the attending physician if the blood sugar level was less than 60 mg/dL, the licensed nurse did not take these actions. This oversight was confirmed during interviews and record reviews with the facility's staff. Further deficiencies were noted when the resident became nonverbally responsive later the same day. The resident's heart rate and oxygen saturation were below normal, yet the attending physician was not promptly notified of this significant change in condition. The facility's Nursing Manual and policies require immediate notification of the physician in such emergency situations, but this protocol was not followed, leading to the resident being transferred to a general acute care hospital. The facility's failure to adhere to its own policies and the physician's orders placed the resident at risk for severe medical complications. The Director of Nursing acknowledged that the resident should have received the Glucagon as ordered and that the physician should have been notified of the low blood sugar level. The facility's manual and policies clearly outline the steps to be taken in cases of hypoglycemia and significant changes in a resident's condition, but these were not implemented in this instance.
Failure to Provide Effective Communication for Resident with Disabilities
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding communication barriers, resulting in significant deficiencies in the care of a resident with hearing, visual, and speech disabilities. The resident, who had a history of deafness, visual impairment, and dementia, was not provided with effective communication aids or interpreter services, despite the facility's policy requiring such accommodations. Staff did not utilize communication tools like a writing board or American Sign Language (ASL) to communicate with the resident, leading to the resident's frustration, agitation, and attempts to leave the facility. The resident's care plan, which noted the use of a communication board, was not revised even after it was determined that the resident could not effectively use it. The facility also failed to assess the resident's behaviors of agitation and frustration, as well as the cause of her poor oral intake, which led to a significant weight loss. Despite the resident's family member informing the facility that ASL was the preferred method of communication, the facility did not have staff trained in ASL or access to interpreter services, relying instead on ineffective hand gestures and written communication. Observations and interviews revealed that staff were aware of the communication barriers but did not take appropriate steps to address them. The resident was observed displaying signs of frustration and attempting to communicate through hand gestures, which staff could not understand. The facility's Director of Nursing acknowledged the communication issues and the lack of interpreter services, which were supposed to be available according to the facility's policy. This deficiency in communication contributed to the resident's distress and eventual transfer to a general acute care hospital due to abdominal pain.
Infection Preventionist Fails to Complete Required Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP), responsible for the Infection Prevention Control Program, completed the required ten hours of continuing education training on an annual basis. During an interview, the IP admitted to not having documentation of completing the necessary continuing education hours for the year 2023. Although the IP completed continuing education hours when renewing his nursing license, these hours were not completed in 2023. The IP acknowledged his responsibility to complete these hours annually to stay informed about new guidelines and studies related to infection prevention and control. The Director of Nursing (DON) confirmed that the IP was responsible for educating the staff on current infection prevention and control practices. The DON emphasized the importance of the IP being updated on current news and training sources to effectively educate others. The lack of completion of the ten hours of continuing education by the IP raised concerns about the potential for missing important changes and not being up to date with current infection control practices. A review of the California Department of Public Health All Facilities Letter indicated that the IP should complete ten hours of continuing education annually, and facilities should support IP staff in staying informed through recognized infection prevention and control associations.
Failure to Obtain Informed Consent for Restraints
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were informed in advance about the risks and benefits of using physical restraints. This deficiency was observed in five residents, where the facility did not obtain informed consent for the use of restraints such as bedrails and lap trays. For instance, Resident 66 and Resident 71 had bedrails and their beds placed against the wall without any informed consent documented, despite their cognitive impairments and the potential restriction of movement these restraints could cause. Resident 15 was observed with a lap tray fastened to his wheelchair, which was used as a restraint to prevent falls. However, the responsible party for Resident 15 was not informed that the lap tray was being used as a restraint, and there was no documentation of informed consent. The responsible party believed the tray was for food and was unaware of its restrictive purpose. This lack of communication and documentation highlights the facility's failure to adhere to its policy on informed consent. Similarly, Residents 88 and 16 were found with bedrails and their beds placed against the wall, restricting their movement without informed consent from their responsible parties. The facility's policy required that informed consent be obtained before using any restraint, but this was not followed. Interviews with staff confirmed that the necessary discussions and documentation were not completed, leading to a violation of the residents' rights to make informed decisions about their care.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that 10 of 25 sampled residents were free from the use of physical restraints, as required by regulations. Specifically, the facility did not obtain physician orders, care plans, or informed consent for the use of bedrails for several residents. Additionally, the beds of these residents were placed against the wall, further restricting their ability to move freely and increasing the risk of entrapment and injury. Observations and interviews confirmed that these practices were in place without proper documentation or assessment of the necessity for such restraints. For some residents, the facility did not implement less restrictive measures before resorting to the use of bedrails and placing beds against the wall. The Interdisciplinary Team (IDT) failed to perform quarterly assessments to ensure the least restrictive measures were taken, particularly in the case of one resident who was at risk of being restrained without indication. This lack of assessment and documentation led to the inappropriate use of restraints, which could potentially cause physical and psychosocial harm to the residents involved. The report highlights specific cases where residents were observed with bedrails and beds against the wall, without the necessary physician orders or informed consent. Interviews with staff, including registered nurse supervisors and licensed vocational nurses, revealed a lack of understanding and adherence to the facility's policies regarding the use of restraints. The Director of Nursing acknowledged that the facility's policy required alternative methods of behavioral control to be attempted and documented before using physical restraints, which was not done in these cases.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for four residents, leading to deficiencies in their care. Resident 98, who was severely cognitively impaired and required total assistance with toileting hygiene, was not checked for a soiled diaper in a timely manner. Despite the facility's policy to check and change bedbound residents every two hours, Resident 98 was left unchanged for an extended period, resulting in a urinary tract infection. Interviews with staff confirmed that the resident was not repositioned or cleaned as required, which could lead to discomfort and skin breakdown. Residents 13, 16, and 47 were observed with long and dirty fingernails, indicating a lack of proper nail care. Resident 16, who was dependent on staff for personal hygiene, had a black substance under his fingernails for several days. Staff interviews revealed that CNAs were responsible for daily nail care, but this was not performed, putting the resident at risk for infection. Similarly, Resident 47, who was totally dependent on staff for hygiene, was seen with long, dirty fingernails over multiple days, and staff acknowledged the importance of maintaining clean nails to prevent bacterial growth and potential hospitalization. Resident 13, who required assistance with activities of daily living, also had long and dirty fingernails. The resident expressed a desire for staff to clean and cut his nails, but this was not done. Interviews with nursing staff and the DON confirmed that CNAs were responsible for ensuring residents' nails were clean and trimmed. The facility's policy emphasized the importance of cleanliness and grooming, but these standards were not met, compromising the residents' comfort, dignity, and safety.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess the medical need for bed rails, obtain physician orders, and secure informed consent for their use for nine residents. Observations revealed that residents had bed rails in the up position without documented assessments or orders. For instance, Resident 93, who had intact cognitive skills and required moderate assistance for daily activities, was observed with bilateral siderails up without any documented medical need or consent. Similarly, Resident 40, with impaired cognitive skills, was unaware of the reason for the siderails and expressed a desire for more space around the bed. Further observations and interviews highlighted that several residents, including Residents 13, 36, and 112, had bed rails without proper assessments or physician orders. Resident 112, with intact cognitive skills, stated she did not need siderails and was unaware of their purpose. The facility's Registered Nurse Supervisor confirmed that there were no assessments, physician orders, or informed consent for the use of siderails for these residents, indicating a systemic issue in the facility's process for implementing bed rails. The facility's policy required a Bed Rail Entrapment Risk Assessment and informed consent before the installation of bed rails, which was not followed. Interviews with staff, including the Director of Nursing, revealed that the facility did not conduct necessary assessments for entrapment risks, placing residents at potential risk for injury. The facility's failure to adhere to its policies and procedures regarding the use of bed rails resulted in a deficiency that could lead to accidents, injuries, and hazards such as entrapment and falls for the residents involved.
Deficiencies in Diet Preparation and Service
Penalty
Summary
The facility failed to ensure that staff followed food production recipes and fortified diet guidelines during lunch service. Specifically, fortified diets were not prepared and served to 10 residents who were prescribed such diets. During the lunch service tray line observation, it was noted that the staff member responsible for communicating diet orders did not inform the server about the fortified diet requirements, resulting in the omission of additional food items meant to increase caloric intake. The dietary supervisor confirmed that fortified diets were intended for residents losing weight or not consuming enough calories, and acknowledged that the fortified foods were not provided as required. Additionally, the facility did not properly prepare pureed diets for 17 residents who required them. Observations revealed that the pureed vegetables served were lumpy and contained chunks, contrary to the required smooth consistency that does not require chewing. The staff member responsible for preparing the pureed food admitted to rushing the process, resulting in improperly blended vegetables. The dietary supervisor confirmed that the pureed food required further blending to achieve the necessary consistency for safe consumption by residents with chewing and swallowing difficulties. Furthermore, the facility did not adhere to the prescribed portion sizes for residents on mechanical soft and finely chopped diets. During the lunch service, a staff member used a smaller scoop than required, resulting in residents receiving less meatloaf than specified in the menu. This deviation from the menu led to residents receiving less protein than intended. The dietary supervisor acknowledged the error and confirmed that the portion sizes served did not meet the menu's requirements.
Deficiencies in Food Storage, Ice Machine Maintenance, and Sanitization Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. In the walk-in refrigerator, a package of ready-to-eat ham and several packages of meat, including breaded fish, diced pork, and ground beef, were found without thaw dates. Additionally, a plastic storage bag with a breaded food item in the reach-in freezer lacked a label or date. The Dietary Supervisor acknowledged that these items should have been labeled to prevent exceeding the thawing and storing period. The facility's policy required labeling and dating of refrigerated or frozen food taken from original packaging. The ice machine in the kitchen was not maintained in a clean manner, with black residue observed inside the compartment. The Maintenance Supervisor admitted that the ice machine was due for cleaning and that the residue could contaminate the ice. The facility's policy mandated monthly cleaning and sanitizing of the ice machine, with special attention to the door molding and lid. The U.S. Food and Drug Administration Food Code also required routine cleaning of equipment contacting food to prevent microorganism accumulation. During food preparation, a dietary aide did not follow proper cleaning and sanitizing procedures. After mixing raw ground beef, the aide placed used spoons in the food preparation sink, which was later used to drain cooked vegetables. The aide cleaned the sink with sanitizer but left pieces of raw ground beef at the bottom. The facility's policy required removing debris, washing surfaces with detergent, rinsing with water, and spraying with sanitizer without rinsing. The dietary aide's job description included washing and sanitizing dishes, utensils, and equipment according to standard procedures.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and update comprehensive care plans for 15 out of 25 residents, leading to several deficiencies. For Resident 88, the facility did not create a care plan for the use of Buspirone or address the problematic behavior of auditory hallucinations. Similarly, Resident 17's use of Ativan was not care planned, which could result in unmonitored side effects. The Director of Nursing (DON) acknowledged these oversights, emphasizing the importance of care plans in monitoring adverse effects and ensuring resident safety. Resident 10's behavior of wandering into another resident's room was not care planned, despite a history of such incidents. This lack of planning led to a situation where Resident 10 was found in a compromising position with Resident 13, raising concerns about resident safety and supervision. The DON admitted that Resident 10's wandering should have been addressed in a care plan due to her history of dementia and forgetfulness. Additionally, the facility did not develop care plans for the use of physical restraints and other devices for several residents, including Residents 66, 109, 11, 15, 71, 16, 88, 93, 40, 13, 36, and 112. This included the use of dentures, bedrails, and lap trays, which could pose risks if not properly monitored. The DON and other staff members recognized the need for care plans to communicate the specific interventions and monitoring required to ensure resident safety and well-being.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate entries on the Minimum Data Set (MDS) for two residents, which could potentially affect their care plans and delivery of necessary services. For Resident 17, the MDS did not include the presence of hallucinations, despite evidence from various records indicating that the resident experienced auditory hallucinations. The Director of Social Services (DSS) acknowledged the oversight, noting that the MDS assessment was incorrect and could mislead the healthcare team regarding medication management. Resident 17's medical records, including the Admission Record, Order Summary Report, and Monthly Psychotropic Drug Management, documented the presence of auditory hallucinations. Interviews with the DSS and the Director of Nursing (DON) confirmed that the MDS assessment was inaccurate, which could impact decisions about the resident's antipsychotic medication and overall care plan. For Resident 88, the MDS assessment failed to include an anxiety disorder diagnosis, despite the resident receiving medication for anxiety and having the diagnosis documented in psychiatric notes. The DON confirmed the inaccuracy, stating that the omission could negatively impact care planning and the resident's quality of life. The facility's policy requires accurate resident assessments to meet state and federal requirements, which was not adhered to in these cases.
Inaccurate PASRR Assessments for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) assessments for two residents, which is a federal requirement to prevent inappropriate placement of individuals with mental disorders or intellectual disabilities in nursing homes. Resident 109 was admitted with diagnoses of schizophrenia and depression, and although a PASRR Level I Screening was completed, a Level II Mental Health Evaluation was not conducted due to a duplicate Level I Screening on file. The Registered Nurse Supervisor acknowledged that the facility did not follow up to ensure the Level II Evaluation was completed, potentially depriving Resident 109 of necessary mental health services. Similarly, Resident 25, who was readmitted with diagnoses of schizophrenia and depression, had an inaccurate PASRR Level I Screening that incorrectly indicated the absence of a serious mental disorder. This error led to the omission of a required Level II Mental Health Evaluation, which could have identified necessary mental health services for Resident 25. The facility's policy mandates screening for mental illness and coordination with state agencies, but these procedures were not properly executed for the two residents, as confirmed by the Registered Nurse Supervisor.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer in a resident, identified as Resident 58, who was admitted without any skin breakdown or pressure ulcers. Upon readmission, Resident 58 required total assistance with all activities of daily living and was noted to have developed a wound on the sacrum, which progressively worsened over time. The initial wound was documented on 5/11/2024, and by 6/5/2024, it had increased significantly in size. The care plan for Resident 58 included turning and repositioning every two hours, but there were no interventions for increased frequency of incontinence care or the use of moisture barrier creams, despite the resident's condition of constant fecal incontinence. Interviews with facility staff, including the Registered Nurse Supervisor, Director of Nursing, and Treatment Nurse, revealed inconsistencies and inadequacies in the care plan and interventions for Resident 58. The staff acknowledged the challenges in maintaining the resident's skin integrity due to constant fecal incontinence and the lack of specific interventions in the care plan to address this issue. The Director of Nursing was unable to determine the stage of the wound due to discrepancies in the care plans, which indicated different stages for the pressure ulcer. The facility's policy and procedure for pressure ulcer management emphasized the importance of risk assessment, relieving pressure, good skin care, and nutritional and incontinence assessments. However, these protocols were not adequately followed for Resident 58, as evidenced by the lack of frequent repositioning, skin checks, and the use of protective moisture barrier creams. The failure to implement these interventions contributed to the development and worsening of the pressure ulcer, highlighting a deficiency in the facility's care practices.
Hazardous Tools Left Unattended in Resident Room
Penalty
Summary
The facility failed to maintain a safe environment for residents by leaving hazardous maintenance tools and nails in a shared room occupied by two residents. Resident 10, who has dementia, schizophrenia, and bipolar disorder, was admitted to the facility on 7/22/2016 and readmitted on 12/21/2022. The resident was assessed as mildly cognitively impaired and required total assistance with personal care. Resident 51, diagnosed with multiple sclerosis, was admitted on 11/07/2017 and readmitted on 5/23/2024. This resident was cognitively intact but required total assistance with all activities of daily living. During an observation, a rolling cart with used nails, screws, and other sharp objects was found within reach of the sleeping residents. Maintenance Assistant 1 admitted to leaving the tools unattended for five minutes while fixing the floor, acknowledging the safety concern. Interviews with RN 1, the Maintenance Supervisor, and the Director of Nursing confirmed that leaving tools unattended in resident rooms is against facility policy due to the risk of injury. The facility's policy emphasizes maintaining safety by identifying hazardous areas and unsafe practices.
Failure to Implement Dietician's Recommendations for Resident's Feeding Program
Penalty
Summary
The facility failed to implement the Registered Dietician's (RD) recommendations for a resident, identified as Resident 66, who was at risk for further weight loss due to variable oral intake. Despite the RD's recommendation for Resident 66 to be initiated on a Restorative Nursing Aid (RNA) feeding program to promote increased oral intake and weight stabilization, the staff were unaware of these recommendations. The resident, who had a history of generalized muscle weakness and dysphagia, was observed feeding himself without any staff assistance or supervision, contrary to the RD's recommendations. Interviews with facility staff, including a Certified Nursing Assistant (CNA), a Registered Nurse Supervisor (RNS), and the Director of Nursing (DON), revealed a lack of awareness and implementation of the RD's recommendations. The dietary progress note indicating the need for an RNA feeding program was not reflected in the resident's active physician orders, and the staff responsible for implementing such programs were not informed. This oversight increased the risk of further weight loss for Resident 66, who had already experienced a significant weight loss of 39 pounds over six months.
Failure to Implement Non-Pharmacological Interventions for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for behavior management by not utilizing effective communication techniques before administering psychotropic medication to a resident who was deaf and visually impaired. The resident, who had a history of deafness, visual impairment, and dementia, was admitted without a diagnosis of anxiety disorder. Despite this, the facility administered lorazepam to the resident on multiple occasions without first attempting non-pharmacological interventions or assessing the resident's preferred communication method. The resident exhibited signs of frustration and agitation due to an inability to communicate effectively with the staff. Progress notes indicated episodes of aggressive behavior, restlessness, and attempts to leave the facility, yet there were no documented efforts to use the resident's preferred communication method, such as American Sign Language (ASL), a communication board, or writing pad. The facility was aware of the resident's communication needs but did not have interpreter services available, relying instead on family members, which was against the facility's policy. Interviews with staff and family members revealed that the facility did not have the necessary services in place to communicate with the resident effectively. The Physician Assistant who assessed the resident did not use an interpreter during evaluations, leading to potentially inaccurate assessments. The Director of Nursing acknowledged the lack of non-pharmacological interventions and communication barriers, which contributed to the resident's anxiety and the subsequent administration of psychotropic medication without addressing the underlying causes.
Improper Storage of Gabapentin Solution
Penalty
Summary
The facility failed to ensure proper storage of medications as per the manufacturer's requirements, specifically concerning a bottle of Gabapentin 250 mg per 5 ml solution for a resident. During an observation and interview, it was found that the Gabapentin solution was stored at room temperature in Station 2 Medication Cart 2, contrary to the manufacturer's instructions that it should be refrigerated. The Licensed Vocational Nurse (LVN 1) acknowledged that the medication was not returned to the refrigerator after each dose, as it was needed multiple times per day by the resident. The facility's policy and procedure on the storage of medications indicated that medications requiring refrigeration should be kept in a refrigerator with a thermometer for temperature monitoring. However, this policy was not adhered to in the case of the Gabapentin solution for the resident, which was used to treat nerve pain. The LVN expressed concern that improper storage could render the medication ineffective, potentially leading to increased pain for the resident.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, specifically for Resident 112, who was served a meal containing beef despite having expressed a dislike for it. During an observation and interview, Resident 112 was found eating ice cream instead of the lunch provided, which included meatloaf, steamed vegetables, mashed potatoes, cornbread, and milk. The resident stated that she had informed the dietary staff of her dislike for beef, yet continued to receive it. A review of the meal tray ticket confirmed that Resident 112 was on a regular, mechanical soft diet and had documented dislikes for beef, coffee, pork, salad, and pasta. The Dietary Supervisor confirmed the presence of meatloaf on Resident 112's tray and explained the process of checking meal trays, which included three checks before leaving the kitchen. Despite these checks, the resident's preferences were not honored. The Director of Nursing emphasized the importance of respecting residents' food preferences to prevent malnutrition. The facility's policy indicated that substitutes should be provided for disliked foods, but this was not adhered to in the case of Resident 112.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was assessed as requiring moderate assistance while walking. Despite the physical therapist's evaluation indicating that the resident needed moderate assistance, the resident was allowed to walk independently, leading to an avoidable fall. The resident, who had severe cognitive impairment and was at high risk for falls, fell in the front lobby, resulting in a head injury and a right hip fracture that required surgical intervention. The resident's care plan and physical therapy evaluation highlighted the need for supervision due to generalized weakness, poor judgment, and gait instability. However, there was a communication gap between the rehabilitation department and the nursing staff, as the physical therapy assistant assumed verbal communication would suffice, and the nursing staff was not made aware of the resident's need for assistance. This lack of communication contributed to the resident walking unsupervised and ultimately falling. Interviews with staff revealed that the resident often walked independently without assistive devices, despite being a high fall risk. The security guard and nursing staff observed the resident walking alone frequently, and the director of nursing acknowledged the resident's impulsive behavior and fall risk. The facility's policy on fall prevention and management was not effectively implemented, as the necessary precautions and supervision were not provided to prevent the fall.
Improper Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to accurately obtain blood pressure readings to determine if two residents had orthostatic hypotension. This deficiency was identified during a review of the residents' records and interviews with staff. The facility's procedure for taking orthostatic blood pressure readings was not followed correctly, as the blood pressures were taken out of order and with incorrect timing intervals, which could lead to inaccurate assessments of the residents' conditions. Resident 1 was admitted with multiple diagnoses, including muscle weakness, schizophrenia, epilepsy, cerebral infarction, heart failure, and difficulty walking. The resident's care plan indicated a high risk for falls and injuries, and the medication administration record required orthostatic blood pressure monitoring. However, the blood pressure readings were not taken in the correct sequence or with appropriate timing, as evidenced by the records showing inconsistent timing and lack of position documentation. Resident 2 also had multiple diagnoses, including muscle weakness, abnormalities of gait, paranoid schizophrenia, and COPD. The resident's care plan highlighted a high risk for falls and injuries, and the order summary report required orthostatic blood pressure monitoring. Similar to Resident 1, the blood pressure readings for Resident 2 were not conducted according to the facility's policy, with incorrect timing and lack of position documentation. Interviews with the LVN and DON confirmed the improper procedure and documentation, which could prevent accurate medical intervention.
Failure to Implement Care Plan for Resident Requiring Two-Staff Assist
Penalty
Summary
The facility failed to implement the care plan for a resident who required a two-staff assist for turning and repositioning. The resident, admitted with diagnoses including muscle weakness and gait abnormalities, was assessed as needing substantial assistance for mobility tasks. Despite the care plan indicating a high risk for falls and injuries and specifying the need for two staff members to assist in turning and repositioning, certified nurse assistants (CNAs) documented using only one staff member for these tasks. Interviews revealed that the CNAs were not aware of the requirement for two staff members, as this information was not communicated effectively by the licensed vocational nurses (LVNs) or registered nurses (RNs). The facility's policy emphasized the importance of checking the care plan and being aware of resident limitations, but this was not adhered to, leading to a potential risk for the resident's safety.
Failure to Notify Physician of Behavioral Changes
Penalty
Summary
The facility staff failed to notify the physician of behavior changes for one resident, which had the potential to result in harm to another resident. Resident 1, who was severely cognitively impaired and diagnosed with dementia, anxiety, and paranoid schizophrenia, was attacked by Resident 2. Resident 2 had a history of schizophrenia, homicidal ideations, and suicidal ideations, and was on close monitoring for aggressive behavior. Despite this, Resident 2 was taken off monitoring shortly before the incident without proper documentation or physician notification of the behavior changes. On 3/17/2024, Resident 2 was noted to have struck out at staff and other residents, but there was no documentation that the physician was notified of this change in behavior. Subsequently, on 3/23/2024, Resident 2 attacked Resident 1 in an unwitnessed incident, leading to Resident 1 being sent to the hospital with facial injuries. Interviews with staff and review of records revealed that the facility's policy on notifying physicians of behavioral deviations was not followed, as there was no documentation of physician notification or an SBAR note for the incident on 3/17/2024.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting a resident-to-resident altercation to the State Survey Agency (SA) within the required 2-hour timeframe. Resident 1, who was severely cognitively impaired and diagnosed with dementia, anxiety, and paranoid schizophrenia, was attacked by Resident 2, who had schizophrenia, homicidal ideations, and suicidal ideations. The incident occurred on 3/23/2024 at 8:00 a.m., but the initial fax report to the SA did not go through, and the report was only successfully sent on 3/27/2024 along with the 5-day investigative report. This delay in reporting was confirmed during interviews with the Administrator and other staff members, who acknowledged the requirement to report abuse within 2 hours. Resident 1 was observed lying in bed and unresponsive to verbal stimuli during an observation on 4/9/2024. The incident was also confirmed by Resident 1's Responsible Party, who was informed by the facility that Resident 1 had been sent to the hospital due to facial injuries sustained from the attack. The facility's policy on patient abuse and mistreatment, dated 10/2022, clearly states that all alleged and substantiated violations must be reported to the state agency within the required timeframes, which was not adhered to in this case.
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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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