Live Oak Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 537 W Live Oak, San Gabriel, California 91776
- CMS Provider Number
- 056127
- Inspections on file
- 58
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Live Oak Rehab Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and dependence in ADLs was previously subjected to an attempted kiss in a hallway by another resident with dementia, psychosis, and largely intact cognition. Although this earlier inappropriate contact was stopped by an LVN, the second resident’s care plan was not updated to address the behavior. Later, a CNA found the same resident on top of the cognitively impaired resident in her room, kissing her on the lips and touching her breast while she tried to turn her face away, and the resident later nonverbally confirmed being touched on her breasts and genital area. Staff interviews and record review showed that the lack of a behavior-focused care plan and monitoring after the first incident contributed to the subsequent sexual abuse.
A resident with aphasia, moderate cognitive impairment, and a prior history of gangrene from wrapping behavior was observed with red discoloration and a constricting mark on a finger while tangled call light cords and coiled bed control cables hung within reach on the bed. Staff, including an LVN and multiple CNAs, acknowledged that the resident had a known pattern of wrapping cords, gown strings, and GT tubing around her fingers and that these items posed a safety hazard, yet cords and cables were left accessible and prior incidents were not reported to other staff. The DON confirmed the resident’s history and behavior, recognized the cords and cables as hazards, and acknowledged that the resident’s care plan did not include specific problems or interventions addressing her wrapping behavior, despite a facility policy requiring identification and mitigation of safety risks.
The facility failed to report an allegation of resident-to-resident abuse to required agencies within the two-hour timeframe specified in its abuse policy. Two residents with dementia and significant ADL needs were involved in an incident in the activity/dining room in which one allegedly struck the other, as observed by a CNA. The CNA stated an LVN said she would make a report, but the CNA did not notify the Administrator or other staff that day, and the LVN reported learning of the allegation the following day. Several days later, the DSD informed the DON and Administrator, who then conducted an internal investigation but did not notify the State Survey Agency, APS, law enforcement, or other required entities, despite facility policy defining such alleged hitting or slapping as abuse that must be reported within two hours.
A resident with heart failure, severe cognitive impairment, and dependence in most ADLs did not have transportation arranged by facility staff for scheduled outside PCP appointments. Family reported two missed PCP appointments, while the social worker stated only one transportation arrangement had been made and that she was unaware of one of the appointments. Review of physician orders showed a one-time order for an outside appointment on one date but no order for the later PCP visit, and licensed nurses were responsible for placing transportation orders in the transportation communication binder.
A resident with a history of falls, muscle weakness, and dementia experienced an unwitnessed fall. The LVN who discovered the fall did not immediately notify the physician, DON, or responsible party, despite facility policy and the resident's care plan requiring such notification. The incident was only reported several days later, as confirmed by record review and staff interviews.
The facility did not consistently post accurate and updated nurse staffing and DHPPD information as required by its policy, resulting in outdated postings and discrepancies between scheduled and actual staff present. Staff responsible for posting were not available or trained to complete the task on weekends and holidays, leading to residents and visitors not being informed of current staffing levels.
A resident with cognitive impairment and recent hip surgery sustained a right hip dislocation, which was confirmed by x-ray and led to hospital transfer. The facility did not report this unusual occurrence to the state agency within the required 24-hour timeframe, contrary to its own policy.
A resident with multiple complex diagnoses, including dementia and recent hip surgery, developed a right hip dislocation of unknown origin shortly after admission. Despite facility policy requiring investigation of injuries of unknown source, no investigation was conducted, as staff incorrectly assumed the injury predated admission. Both the DON and administrator confirmed the lack of investigation, contrary to facility procedures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Surveyors observed that the care planning documentation did not fully meet regulatory requirements for individualized and comprehensive care.
A CNA physically abused a resident with severe cognitive impairment by grabbing the resident's shirt in a manner that caused choking and then slapping the resident's back after the resident threw water at the CNA. The incident was witnessed by staff and confirmed by surveillance video, and was in direct violation of the facility's abuse prevention policy.
The facility failed to secure medications properly, with OTC drugs stored in an unlocked central supply room and a vial of Lorazepam found in an unlocked fridge. The storage room, accessible to various staff, contained unlocked cupboards with OTC medications, violating the facility's policy requiring secure storage accessible only to authorized personnel.
The facility failed to provide appetizing and palatable meals to two residents, leading to dissatisfaction and potential risks for unplanned weight loss. One resident, with dietary preferences due to medical conditions, received meals that did not align with her needs. Another resident expressed dissatisfaction with the quality and repetitiveness of meals, leading to skipped meals. Test trays confirmed poor meal quality, with issues in texture and flavor, contrary to the facility's policies on food preparation and accommodation of needs.
The facility failed to follow proper food handling practices, including storing expired food, mixing personal and resident food, and improper labeling of dry food items. Chemicals were stored with food, and a staff member did not practice proper hand hygiene, leading to potential cross-contamination. These actions violated the facility's policies and put residents at risk of foodborne illnesses.
A facility failed to maintain a resident's dignity during mealtime assistance when a CNA stood above the resident while feeding, contrary to policy. The resident, with cognitive impairment and requiring assistance, was observed being fed by a standing CNA, which was confirmed as inappropriate by the DON.
A facility failed to conduct a Level 2 PASARR for a resident with schizophrenia, despite a Level 1 PASARR indicating the need for further evaluation. The resident, who had severe impaired cognition and required assistance with daily activities, exhibited confusion and aggression. The facility's failure to follow up on the necessary evaluation left them without recommendations for the specialized care needed for the resident's mental health condition.
A resident with multiple fractures experienced inadequate pain management due to the facility's failure to update her care plan to include a physician-ordered Fentanyl patch. Despite the resident's constant pain, the care plan was not revised to reflect the new intervention, leading to a lapse in pain management. The DON confirmed the care plan should have included details on the Fentanyl patch's administration and handling.
A non-English speaking resident with dementia did not have access to a communication board or translation services, leading to unmet needs and confusion. The resident was dependent on staff for daily activities and had severe cognitive impairment. Staff failed to use available resources for communication, and the facility's policy for supporting communication was not followed.
A resident requiring total assistance with personal hygiene was found with dirty fingernails and a thick brown crust around the nail bed, indicating a lack of proper nail care. Despite the resident's medical conditions and need for dependent care, observations and interviews revealed that the facility staff failed to maintain the resident's nail hygiene, potentially leading to infection.
A resident with hemiplegia and aphasia was not provided with age-appropriate activities, negatively affecting his well-being. Despite his interest in music, reading, and news, the facility failed to assess and offer suitable activities. The resident expressed dissatisfaction with the options available, and staff confirmed the lack of age-appropriate activities. The facility's policies on dignity and accommodation of needs were not effectively implemented.
A resident with significant weight loss and cognitive impairments did not receive the required feeding assistance as per the RNA program in place. Staff failed to document the resident's nutritional intake accurately, with CNA unaware of the resident's dietary needs and RNA occupied with other residents. The facility's policies on feeding assistance and weight management were not followed, risking further health complications for the resident.
A resident with multiple fractures experienced severe pain due to the facility's failure to reorder a Fentanyl patch in advance, as per policy. The patch was not available when needed, and the resident's pain was not reassessed or managed effectively, despite her expressing severe discomfort. The staff did not administer Norco or follow the care plan, resulting in the resident suffering unnecessary pain.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to potential re-traumatization. The resident, with a history of sexual assault, required specific care preferences, such as female staff and drawn curtains, which were not communicated to the staff. The absence of a trauma assessment and care plan for the resident's PTSD was a significant oversight, as acknowledged by the Social Services Director and DON.
A facility failed to follow a physician's order to administer Oyster Shell Calcium/D tablets with food to a resident with dementia and fractures. The LVN gave the medication without food, believing it unnecessary since the resident had eaten earlier. The IPN confirmed that medications ordered with food should be given within 15-20 minutes of eating to prevent adverse effects and ensure absorption.
A resident with GERD and a dislike for tomatoes was repeatedly served meals containing tomatoes, despite her preferences being documented. Additionally, a specific meal request due to a toothache was not honored, leading to frustration. The facility's policies for accommodating dietary needs were not followed, resulting in miscommunication and unmet dietary preferences.
The facility failed to follow infection control measures for two residents. A resident's Foley catheter drainage bag was found touching the floor without a basin, contrary to the care plan. Another resident's G-tube was handled by a nurse without wearing a gown, violating Enhanced Barrier Precautions. These deficiencies were confirmed by staff interviews and facility policies.
A visitor failed to wear required PPE while visiting a resident in contact isolation due to Klebsiella pneumoniae and UTI. Despite signage and facility policy mandating gloves and gowns, the visitor was observed without them, risking the spread of infection. Staff confirmed the importance of PPE to protect residents and visitors.
Two residents in the facility were found with call lights out of reach, posing a risk for delayed care and potential injury. One resident, with hemiplegia and cognitive impairment, had their call light on the floor, while another resident with hemiparesis had theirs on a nightstand. A CNA and the DON acknowledged the importance of accessible call lights for timely assistance.
The facility did not post the required nurse staffing information at the start of each shift, as observed on a specific day. The Administrator confirmed that the Daily Nursing Staffing form was not posted for the morning shift, and the Director of Staff Development admitted forgetting to update and post the information. This oversight was contrary to the facility's policy, which requires daily posting of nurse staffing data for each shift.
The facility inaccurately reported 100% COVID-19 vaccination for staff, while only 30% were vaccinated. The Infection Preventionist Nurse lacked a current vaccination list, and the facility did not have copies of vaccination cards for some staff, violating their policy. This placed residents and staff at risk for COVID-19 infection.
Two residents experienced delays in call light responses, with one waiting over an hour and another waiting 15-20 minutes. Both residents required assistance with daily activities due to muscle weakness. The facility's policy mandates call lights be answered within five minutes, a standard not met in these instances.
A resident was administered Ativan without a physician's order and without a specific target behavior documented, contrary to facility policy. The resident, diagnosed with dementia and anxiety disorders, received the medication for vague panicky feelings. The medication was not removed from the cart after discontinuation, risking mistaken administration. The DON acknowledged the incomplete order and the need for specific behavior monitoring.
A resident with multiple medical conditions was unnecessarily restrained by two LVNs using a white linen tied to her wheelchair, restricting her movement. The incident was reported by a CNA and confirmed through interviews and video surveillance. The facility's policy on restraints was not followed, as less restrictive alternatives were not attempted.
The facility failed to promote dignity and respect for five residents, leading to several deficiencies. Residents were found with food on their clothes, exposed in incontinent briefs, and not cleaned after meals. Additionally, personal space was not protected, and meal assistance was provided in an undignified manner.
The facility failed to follow its Advance Directives policy for three residents, leading to deficiencies in documenting and maintaining advance directives. One resident was not informed about the choice to complete an advance directive, while two others had their advance directives missing from their medical records. This failure could lead to staff not knowing the residents' wishes during emergencies.
The facility failed to develop and implement individualized care plans for three residents, leading to unmet needs and potential health risks. One resident's behavior in a shared restroom caused conflicts, another lacked a care plan for IV antibiotic therapy, and a third did not have their anticoagulant therapy monitored for bleeding.
The facility failed to provide consistent restorative nursing services for three residents, leading to missed passive range of motion exercises and improper application of splints. Observations and staff interviews confirmed that the required care was not provided due to staffing shortages and improper documentation.
The facility failed to ensure the head of bed (HOB) was elevated above 30 to 45 degrees during enteral feedings for two residents, leading to potential aspiration risks. Both residents had severe medical conditions requiring strict adherence to feeding protocols, which staff did not follow, as confirmed by multiple observations and interviews.
The facility failed to provide necessary respiratory care services for two residents by not changing oxygen humidifiers and tubing as required and not placing visible oxygen signage, leading to potential health risks.
The facility failed to ensure that residents receiving dialysis care had necessary emergency kits and alert signs at their bedside. This deficiency was observed for three residents, who were found without these critical items, and confirmed by staff interviews and record reviews.
The facility failed to provide necessary social services for two residents, leading to delays in care. One resident's missing hearing aids were not reported to law enforcement as required, and another resident did not receive follow-up dental care for new dentures. These deficiencies resulted from lapses in communication and adherence to facility policies.
The facility failed to label foods with 'use by' dates and did not discard expired food as per policy, leading to potential pathogen exposure. Observations revealed unlabeled and expired items in the kitchen and dry storage, confirmed by the Dietary Trayline and Supervisor.
The facility failed to follow antibiotic stewardship program protocols for eight residents, leading to the prescription of antibiotics without proper surveillance data collection. This deficiency increased the risk of inappropriate antibiotic use and antibiotic-resistant organisms.
The facility failed to disinfect the handles of two laundry washers with an EPA-approved disinfectant solution, as required by their policy. A laundry staff member was observed handling soiled and clean clothes without disinfecting the washer handles, potentially leading to contamination. The Infection Preventionist confirmed the need for disinfection to prevent infection spread.
A resident experienced severe weight loss, dropping 17 pounds in one month, but the facility failed to notify the physician in a timely manner as required by their policies. The licensed nurses and Dietary Supervisor did not follow the protocol for reporting significant weight changes, leading to a delay in addressing the resident's declining nutritional status.
The facility failed to accurately assess a resident's active diagnoses, omitting schizophrenia from the MDS assessment. This led to the absence of a care plan and necessary treatments for the resident's condition, as confirmed by staff interviews and record reviews.
The facility failed to provide necessary assistance with eating for a resident with dementia and anorexia, and did not provide a communication board for another resident with end-stage renal disease and diabetes mellitus, leading to potential declines in their functional abilities.
The facility failed to provide necessary audiology and ENT services for a resident with hearing loss, as per the physician's orders. Despite a physician's order for audiology consults and ENT follow-up treatment, the resident had not received these services, and the resident's hearing loss was not included in the care plan.
The facility failed to ensure the low air loss (LAL) mattress was set correctly for a resident with an unstageable pressure injury. The LAL mattress was observed at 240 mmHg, which was inappropriate for the resident's weight of 187 pounds. Staff confirmed the setting should have been 160 or 200 mmHg, as per the facility's policy, to prevent further skin breakdown.
The facility failed to follow the pharmacist's recommendation to administer Carvedilol with food for a resident with hypertension and end-stage renal disease. Despite the clear recommendation in the Medication Regimen Review, the medication order did not include this instruction, as confirmed by both the LVN and the DON.
Failure to Prevent Resident-to-Resident Sexual Abuse After Prior Inappropriate Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident after a prior incident of inappropriate sexual behavior. One resident (Resident 1) had a history of cerebrovascular disease with cerebral infarction, aphasia, anxiety disorder, and was assessed as moderately impaired in cognitive skills for daily decision-making. Resident 1 was dependent on staff for multiple activities of daily living, including personal hygiene, transfers, and toileting. Another resident (Resident 2) had diagnoses including COPD, psychosis, anxiety disorder, and dementia, but was assessed as cognitively intact and required only supervision or limited assistance with mobility and self-care tasks. On 12/17/2025, a change of condition note documented that Resident 2, while propelling his wheelchair toward his room, stopped in the hallway and attempted to get up and kiss Resident 1 on the cheek while both were in their wheelchairs. LVN 2 intervened and was able to stop Resident 2 from kissing Resident 1 and immediately separated the two residents. Despite this documented attempt at inappropriate physical contact, Resident 2’s care plan was not updated to address this behavior. During a later review, the MDS Coordinator confirmed that Resident 2 did not have a care plan for inappropriate behavior related to the attempted kiss and stated that a care plan with interventions such as close monitoring and activities to keep Resident 2 occupied should have been developed. On 3/7/2026, CNA 1 observed Resident 1 lying on her bed in her room while Resident 2 was on top of her, touching her breast and kissing her on the lips. CNA 1 reported that Resident 1 was trying to move her face away from Resident 2. LVN 1, summoned to the room, saw CNA 1 wheeling Resident 2 out and was told that Resident 2 had been on top of Resident 1, kissing her lips and touching her breasts; LVN 1 identified this as sexual abuse. In a subsequent interview, Resident 1 nonverbally confirmed that a male resident had entered her room and touched her breasts and the top of her vaginal area, demonstrating the areas touched. Resident 2 denied inappropriate behavior when questioned, stating he only intended a greeting. The Director of Nursing acknowledged that the facility failed to prevent the abuse because another incident occurred between the two residents after the earlier event.
Failure to Control Environmental Hazards for Resident With Known Finger-Wrapping Behavior
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by allowing accessible call light cords and bed control cables for a resident with known behaviors of wrapping items around her fingers. The resident, who had aphasia following cerebral infarction, a history of gangrene on a finger from wrapping behavior prior to admission, and moderate cognitive impairment, was dependent for most activities of daily living. During observation, the resident was seen in a customized wheelchair with red discoloration and a darker red band around her left middle finger, and she nodded when asked if she had placed her finger in the tangled call light cord beside her bed. The resident’s bed was observed with tangled call light cords hanging on the inner side of the upper quarter bed side rail and coiled bed control cables hanging on the upper left side of the bed. Staff interviews confirmed prior knowledge of the resident’s behavior and the associated hazards. An LVN stated the resident could twist and wrap her fingers with the coiled bed control cables and tangled call light cords, and that these should be kept away from the resident because she was not capable of using them. CNAs reported being informed in a staff huddle that the resident liked to play with and tie things around her fingers, and at least two CNAs had personally observed the resident wrapping cords or gown strings and GT tubing around her fingers on previous occasions, but did not report these incidents to other staff. The DON acknowledged the resident’s prior history of gangrene from wrapping behavior, confirmed that tangled cords and cables were safety hazards for this resident, and noted that the resident’s care plan lacked any problem or interventions specific to her wrapping behavior, despite an existing generic risk-for-injury care plan. The facility’s policy on Safety and Supervision of Residents stated that the environment should be as free from accidental hazards as possible and that safety risks are to be identified through training, monitoring, and reporting, but this was not implemented for this resident’s known behavior.
Failure to Timely Report Alleged Resident-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to required local, state, and federal authorities within two hours, as required by facility policy. Two residents were involved in the alleged incident. One resident had chronic respiratory failure, unspecified dementia, and peripheral vascular disease, and was documented in a recent H&P as lacking capacity to understand and make decisions, while a later MDS showed modified independent cognitive skills for daily decision-making and a need for assistance with activities of daily living. The second resident had unspecified dementia, type 2 DM, and peripheral vascular disease, was documented in an H&P as lacking capacity to understand and make decisions, and was assessed on the MDS as having severely impaired cognitive skills and being dependent or needing assistance for most ADLs. On a Sunday, CNA 1 observed an interaction in the activity/dining room and stated it looked as if the second resident struck the first resident. CNA 1 reported that on the day of the alleged incident, an LVN said she would make a report, but CNA 1 did not report the alleged incident to the Administrator or any other facility staff that day. LVN 1 later stated she was informed by a CNA the day after the alleged incident that the second resident allegedly slapped the first resident. The Director of Staffing informed the DON and Administrator of the alleged incident several days later, at which time the DON spoke with CNA 1, who reported that the two residents allegedly hit each other in the activity room. The Administrator acknowledged that the alleged incident occurred on a Sunday and that he was not informed until several days later, after which he investigated the incident internally without reporting it to any outside agencies. The DON stated the facility did not report the alleged incident of abuse because it was investigated within the facility and there was no evidence that it occurred, but also stated that alleged hitting or slapping of a resident is considered abuse and, per facility policy, should have been reported within two hours to the appropriate agencies. The facility’s written policy on abuse, neglect, exploitation, or misappropriation requires that any suspicion of abuse be immediately reported to the Administrator and to specified external agencies, defining “immediately” as within two hours of an allegation involving abuse. Despite this policy, the facility did not report the allegation involving these two residents to the State Survey Agency, APS, law enforcement, or other listed entities.
Failure to Arrange Transportation for Outside PCP Appointments
Penalty
Summary
The facility failed to ensure transportation was arranged for a resident to attend all scheduled outside primary care physician (PCP) appointments as ordered. The resident was admitted with diagnoses including heart failure, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Minimum Data Set dated 7/18/2025 documented that the resident had severely impaired cognitive skills for daily decision making and was dependent in multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, lower body dressing, footwear, and personal hygiene, and required substantial/maximal assistance for transfers and ambulation. These conditions indicated the resident relied on staff for coordination of care and transportation to medical appointments. Family interview revealed that the resident had two outside PCP appointments scheduled on 8/4/2025 and 8/20/2025, and that no transportation was arranged by the facility for either appointment. The social worker stated that only one transportation arrangement had been made by the facility for an outside PCP appointment and explained that a physician order was required to arrange transportation, with licensed nurses responsible for placing the appointment order in the transportation communication binder. The social worker further stated she was unaware of the resident’s 8/20/2025 PCP appointment. Review of the Physician Orders Summary Report dated 7/16/2025 showed an order for a one-time outside appointment on 8/4/2025 at 11:00 AM, but there was no indication of an order for the PCP appointment on 8/20/2025.
Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and responsible party following an unwitnessed fall involving a resident with a history of falls, muscle weakness, dementia, and abnormal gait and mobility. The resident was assessed as being at risk for falls and was severely impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically indicated that the physician should be notified in the event of a fall. Despite these documented risks and care instructions, the resident experienced an unwitnessed fall, and the incident was not reported to the physician or responsible party until several days later. Record reviews and interviews revealed that the fall occurred in the resident's room, where the resident was found on the floor by an LVN. The LVN did not report the incident to the physician, DON, or responsible party, stating she did not think it was significant. The facility's policy required notification of the physician in the event of an accident or incident of unknown source, but this protocol was not followed. The responsible party confirmed they were not informed of the fall, and the delay in notification was acknowledged by facility leadership during interviews.
Failure to Post Accurate and Updated Nurse Staffing Information
Penalty
Summary
The facility failed to ensure accurate and updated posting of Direct Care Service Hours Per Patient Day (DHPPD) and Daily Posted Nurse Staffing in accordance with its own policy. Observations and interviews revealed that the posted staffing information was outdated, with the most recent posting dated several days prior to the survey. Review of sign-in sheets and interviews with the Registered Nurse Supervisor and Payroll staff confirmed discrepancies between scheduled and actual staff present, as well as a lack of clarity regarding who was responsible for posting staffing information on weekends and holidays. The Payroll staff, who typically completed the postings, was not present on weekends or holidays, and other staff were not trained or assigned to complete this task. The facility's policy required that nurse staffing data be posted daily and within two hours of the beginning of each shift, but this was not consistently followed. The Administrator and Payroll staff both acknowledged that the policy was not adhered to, particularly on weekends and holidays when responsible personnel were absent. As a result, residents and visitors were not provided with current information regarding facility census, staffing, and actual hours worked by staff, as required by the facility's procedures.
Failure to Timely Report Resident Injury to State Agency
Penalty
Summary
The facility failed to report an unusual occurrence to the Department within 24 hours as required by its own policy and procedure. Specifically, the facility did not notify the Department when it became aware that a resident had sustained a further injury and dislocation of the right hip. The incident was identified on 1/9/2025, when an x-ray conducted at the facility confirmed the right hip dislocation. The resident, who had a history of right upper thigh fracture, recent right hip joint replacement, encephalopathy, difficulty walking, and muscle weakness, was noted to have moderate cognitive impairment and required substantial to maximal assistance with activities of daily living and mobility. The nursing progress notes and SBAR form indicated that the resident was transferred to a general acute care hospital for further evaluation after complaining of pain and discomfort. During an interview, the facility administrator acknowledged that the injury was not reported to the state agency as required. Review of the facility's policies confirmed that such unusual occurrences and injuries of unknown origin must be reported to appropriate agencies within 24 hours, but this protocol was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown source for one of four sampled residents, as required by its own policy and procedure. The resident in question was admitted with multiple diagnoses, including a right thighbone fracture, aftercare following right hip surgery, Parkinson's disease, and dementia. Upon review of the resident's records, it was found that shortly after admission, the resident experienced pain and discomfort in the hip, which led to an x-ray revealing a right hip dislocation. The resident was subsequently transferred to a general acute care hospital for further evaluation. During interviews, the DON acknowledged that staff did not know how the resident sustained the hip dislocation and admitted that no investigation was conducted, mistakenly believing the injury had occurred prior to admission. The facility's policy, however, clearly states that injuries of unknown origin are to be reported and thoroughly investigated, with the administrator responsible for initiating such investigations. Both the DON and the administrator confirmed that the required investigation was not performed in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized care planning as required.
Physical Abuse of Resident by CNA
Penalty
Summary
A certified nurse assistant (CNA) assigned to provide one-to-one monitoring for a resident with severe cognitive impairment engaged in physical abuse. The resident, who had diagnoses including delirium, depression, dementia, and mood disorder, required varying levels of assistance with daily activities and was noted to have severe impairment in decision-making abilities. On the day of the incident, the CNA grabbed the resident's shirt from the back, causing the shirt to choke the resident at the neck area as the resident stood up from a chair. Following this, as the resident turned and threw a cup of water at the CNA's face, the CNA responded by slapping the resident's back with a loud smacking noise. Multiple staff members, including two other CNAs and the facility administrator, witnessed the incident. The administrator also reviewed surveillance video, which confirmed that the CNA grabbed the resident's shirt and slapped the resident's back. Staff interviews indicated that such physical actions are not permitted, even in response to resident aggression. The facility's policy on abuse, neglect, and exploitation clearly states that residents have the right to be free from abuse, including physical abuse, and that staff are to be adequately prepared for caregiving responsibilities, especially for residents with behavioral or cognitive issues. The CNA's actions were in direct violation of this policy, as confirmed by the administrator and corroborated by video evidence and staff testimony.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications, as observed during a survey. In the central supply room, over-the-counter (OTC) medications such as loperamide, ClearLax, Vitamin D, and fish oil were stored on shelves in an unlocked room. The Maintenance Supervisor confirmed that the gate to the room was unlocked, which was against the facility's policy that requires such medications to be stored securely. In another instance, a liquid vial of Lorazepam, a controlled medication, was found in an unlocked medication fridge. The Registered Nurse Supervisor acknowledged that controlled medications should be kept in a locked refrigerator accessible only to licensed staff. The Director of Nursing emphasized the importance of securing controlled medications to prevent misuse or loss, as per the facility's policy. Additionally, the facility's storage room, which had a door code access, contained unlocked cupboards with various OTC medications. The RN Supervisor confirmed that the storage room was accessible to a wide range of staff, including CNAs and housekeeping, which was not in line with the policy that restricts access to authorized personnel only. The facility's policy mandates that medications be stored securely and only accessible to licensed or authorized staff, which was not adhered to in these instances.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals to two residents, leading to dissatisfaction and potential risks for unplanned weight loss. Resident 61, who has gastro-esophageal reflux disease and type 2 diabetes, was served a meal that did not align with her dietary preferences, as it contained tomatoes, which she dislikes, and was too spicy. Observations of test trays revealed that the meals were not visually appealing, with dull colors and unappetizing textures, such as sticky and gummy mashed potatoes and bland, watery rice. Resident 82, diagnosed with unspecified hypertension, type 2 diabetes, and major depressive disorder, expressed dissatisfaction with the quality of meals, describing the chicken as rubbery and low quality. Despite communicating her concerns to the Dietary Staff Supervisor, she was informed that the menu could not be changed due to budget constraints. The resident reported that the food was not appetizing or flavorful, leading her to sometimes skip meals. Test trays sampled by staff, including the Administrator and Dietary Staff, confirmed the poor quality of the meals, noting issues with texture and flavor. The facility's policies and procedures on food preparation and accommodation of needs were not adhered to, as meals were not prepared to preserve nutritive value, flavor, and appearance, nor were substitutes provided for unacceptable food items.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in its policies and procedures, leading to several deficiencies. During an inspection, it was observed that expired food items, such as an opened bottle of cranberry juice, were stored in Refrigerator 3. Additionally, a staff member's personal food container was found in the same refrigerator, which is against the facility's policy to prevent contamination. Furthermore, dry food items in storage were not labeled with both delivery and use-by dates, which is necessary for proper inventory management and safety. In the kitchen, it was noted that micro-kill germicidal alcohol wipes were stored alongside food items like Nestle ThickenUp instant food and drink thickener, violating the policy that prohibits storing chemicals with food items. Moreover, a dietary staff member was observed not practicing proper hand hygiene. The staff member handled food without washing hands after touching potentially contaminated surfaces, such as the trash can lid, and did not wear gloves when handling ready-to-eat foods, which could lead to cross-contamination. Interviews with the Dietary Staff Supervisor and the Director of Nursing confirmed these observations and acknowledged the potential for cross-contamination and infection control issues. The facility's policies clearly state the importance of hand hygiene and proper storage practices to prevent foodborne illnesses, yet these were not followed, putting residents at risk of exposure to pathogens.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to promote dignity and respect for a resident, identified as Resident 44, during mealtime assistance. Certified Nursing Assistant 6 (CNA 6) was observed standing above the resident's eye level while assisting with feeding, which is against the facility's policy and procedure for maintaining resident dignity. This action was noted during two separate observations, where CNA 6 was seen standing while feeding Resident 44, who was seated in a wheelchair and a merry walker, respectively. Resident 44, who was admitted with diagnoses of metabolic encephalopathy and generalized muscle weakness, required assistance with eating as per her care plan. The facility's policy explicitly states that staff should be at eye level with residents during feeding to ensure dignity and respect. Interviews with CNA 6 and the Director of Nursing confirmed that the staff should not stand over residents while assisting them with meals, aligning with the facility's policy to provide a dignified dining experience.
Failure to Conduct Level 2 PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASARR) was conducted for a resident diagnosed with schizophrenia. The resident was admitted with a diagnosis of schizophrenia and had severe impaired cognition, requiring various levels of assistance for daily activities. Despite a Level 1 PASARR conducted at the hospital indicating the need for a Level 2 evaluation, the facility did not follow up with the appropriate agency to conduct this evaluation. This oversight meant the facility did not have the necessary recommendations for specialized services or care for the resident. Observations and interviews revealed that the resident often exhibited confusion, aggression, and non-compliance with care, which were not adequately addressed due to the lack of a Level 2 PASARR evaluation. The Director of Nursing acknowledged the failure to follow up on the Level 2 PASARR, which placed the resident at risk for unmet needs, as the facility lacked guidance on the appropriate care and services required for the resident's mental health condition.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 197, which resulted in inadequate pain management. Resident 197 was admitted with multiple fractures and was assessed to have constant pain that affected her sleep and daily activities. Despite a physician's order for a Fentanyl patch to manage severe pain, the care plan was not updated to include this pharmacological intervention. This oversight was confirmed during an interview with the Infection Prevention Nurse, who acknowledged that the care plan should have been revised to reflect the new pain management strategy. During an observation and interview, Resident 197 expressed severe pain and indicated that her Fentanyl patch had not been reapplied after removal. The Director of Nursing confirmed that the care plan should have included details on the administration and handling of the Fentanyl patch, including potential side effects and safety measures. The facility's policy requires ongoing assessment and timely updates to care plans as residents' conditions change, which was not adhered to in this case.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a non-English speaking resident, identified as Resident 60, had access to a communication board or translation services, which was necessary for effective communication due to the resident's severe cognitive impairment and dependency on staff for activities of daily living. The resident, who was admitted with a diagnosis of dementia and had severely impaired cognitive skills, was observed to be unable to make herself understood or understand others. The care plan for Resident 60 indicated a risk for unmet needs related to communication difficulties, with interventions including the use of a communication board or translation services. During an observation, a Certified Nursing Assistant (CNA) attempted to communicate with Resident 60 using hand gestures and English, which the resident did not understand, resulting in confusion. The CNA did not find a communication board in the resident's room and did not seek assistance from staff who spoke the resident's language. Interviews with the Director of Staff Development and the Director of Nursing revealed that the staff member who could translate was unavailable, and not all staff had been trained on using translation services. The facility's policy required appropriate support and assistance with communication, which was not provided in this case.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility staff failed to provide adequate nail care for a resident who required total physical assistance with personal hygiene. The resident, identified as Resident 80, was observed with dirty fingernails and a thick brown crust around the nail bed on multiple occasions. The resident's care plan indicated a need for assistance with activities of daily living, including grooming and trimming of fingernails, due to cognitive and physical deficits. Resident 80 was admitted with several medical conditions, including cerebral infarction, respiratory failure, unspecified dementia, and peripheral vascular disease. The resident was assessed as needing dependent care for personal hygiene and other daily activities. Despite these needs, observations revealed that the resident's fingernails were not being properly cleaned or maintained, as evidenced by the presence of dirt and potential fungal infection. Interviews with the resident's family and the Director of Nursing confirmed the deficiency in care. The family member noted the lack of daily cleaning and the presence of fungus on the resident's nails. The Director of Nursing acknowledged that certified nursing assistants were responsible for providing ADL care, including nail cleaning, and stated that it was unacceptable to leave a resident with dirty nails, as it could lead to infection and harm.
Failure to Provide Age-Appropriate Activities for Resident
Penalty
Summary
The facility failed to assess and provide specific resident-preferred activities and interests for a resident, which had the potential to negatively affect the resident's sense of self-worth and psychosocial well-being. The resident was admitted with diagnoses including hemiplegia, unspecified sequelae of nontraumatic intracerebral hemorrhage, and aphasia. The resident's Minimum Data Set (MDS) indicated that it was very important for him to engage in favorite activities, listen to music, read, and keep up with the news. However, the care plan did not adequately address these preferences, and the resident was not provided with activities appropriate for his age. Observations and interviews revealed that the resident spent most of his time in bed using an electronic device and watching television, and he expressed dissatisfaction with the activities offered, stating that there was nothing suitable for his age in the Activity Room. The Certified Nursing Assistant (CNA) confirmed that the resident always refused to participate in activities, possibly due to the lack of age-appropriate options. The Activities Director admitted to not asking the resident about specific activities he wanted to do and acknowledged that staying in the room all day could negatively impact the resident's well-being. The Director of Nursing (DON) emphasized the importance of tailoring activities to the resident's age and ethnicity and stated that the facility lacked a policy for assessing residents' preferred activities annually. The facility's policies on dignity and accommodation of needs highlighted the importance of promoting residents' well-being and accommodating individual preferences, but these were not effectively implemented in the resident's case. The Activity Director's job description also required evaluating residents' interests and ensuring they have an adequate activity plan, which was not fulfilled for this resident.
Failure to Provide Adequate Feeding Assistance and Documentation
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, identified as Resident 79, who was experiencing significant weight loss. Despite being on a Restorative Nursing Assistant (RNA) feeding program for breakfast and lunch, the resident did not receive the necessary assistance as ordered by the physician. The resident, who had a history of metabolic encephalopathy, rectal cancer, dementia, and hemiparesis, was on a therapeutic diet and required a change in food texture. The resident's Minimum Data Set indicated a need for setup or cleanup assistance for eating, and the resident had severe cognitive impairments affecting daily decision-making. On specific dates, the facility staff failed to accurately and timely document the resident's nutritional intake. A review of the resident's records showed discrepancies in the reported food intake, with one instance of no documentation for a meal. Interviews with staff revealed a lack of awareness regarding the resident's weight loss and the RNA feeding program. Certified Nursing Assistant 7 (CNA7) did not assist the resident with eating due to language barriers and was unaware of the resident's dietary needs. Additionally, RNA1, who was responsible for assisting the resident, was occupied with other residents and did not report the resident's low food intake to the nursing staff. The facility's Director of Nursing acknowledged the inadequate documentation and staffing assignments that did not align with the resident's needs. The lack of consistent oversight in the RNA implementation was noted as a risk for further weight loss and health complications for the resident. The facility's policies on the Restorative Feeding Program and Nutrition Impaired/Unplanned Weight Loss were not followed, as staff failed to monitor and document the resident's nutritional intake accurately, compromising the resident's health and dietary needs.
Failure in Timely Pain Management for a Resident
Penalty
Summary
The facility failed to provide timely and effective pain management for Resident 197, who was admitted with multiple fractures and assessed to have constant pain that frequently limited daily activities. The resident's care plan included the use of a Fentanyl patch and Norco for pain management. However, the facility did not reorder the Fentanyl patch five days in advance as per policy, resulting in the patch not being available when needed. This led to the resident experiencing severe pain without the scheduled pain relief. On the day the Fentanyl patch was due to be replaced, it was removed by LVN 1 at 9 AM, but the replacement patch was not applied because it had not been delivered by the pharmacy. Despite the resident expressing severe pain and requesting both the Fentanyl patch and Norco, the staff did not administer the Norco or reassess the resident's pain in a timely manner. The resident was observed in distress, rubbing her leg, grimacing, and crying, indicating a significant lapse in pain management. Interviews with the Infection Prevention Nurse and the Director of Nursing revealed that the facility's procedures for pain assessment and medication ordering were not followed. The charge nurse failed to order the Fentanyl patch in advance, and the resident's pain was not reassessed after the patch was removed. The facility's policy required pain to be reassessed every 30 minutes after the onset of acute pain, but this was not done, leading to the resident suffering unnecessary pain for several hours.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, which could lead to re-traumatization and severe psychosocial harm. The resident, who had a history of sexual assault, was admitted with diagnoses including PTSD, type 2 diabetes mellitus, and major depressive disorder. The resident required varying levels of assistance with daily activities and had moderately impaired cognitive skills for decision-making. During observations and interviews, it was noted that the resident preferred to have her curtains drawn and requested female staff, indicating discomfort with male voices. However, the staff, including CNAs and LVNs, were not informed of the resident's PTSD diagnosis or her specific triggers, such as male presence and light sensitivity. This lack of communication and awareness among the staff about the resident's trauma history and triggers was a significant oversight. The Social Services Director and the Director of Nursing acknowledged the absence of a trauma assessment and a care plan specifically addressing the resident's PTSD and triggers. The facility's policy required behavioral assessments and care plans to be developed based on comprehensive evaluations, but these were not implemented for the resident. The failure to conduct an interdisciplinary team meeting and develop a care plan for the resident's PTSD was a critical deficiency in the facility's care provision.
Failure to Administer Medication with Food as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Oyster Shell Calcium/D tablets to a resident, identified as Resident 54. The physician's order specified that the medication should be given with food. However, during an observation, it was noted that the Licensed Vocational Nurse (LVN 2) administered the medication approximately one and a half hours after the resident had eaten breakfast, without providing any additional food. The LVN believed that since the resident had already eaten earlier, there was no need to provide food with the medication. The resident, who was admitted with a diagnosis of dementia and multiple fractures, required setup assistance with eating due to mildly impaired cognitive skills. The facility's Infection Prevention Nurse (IPN 1) confirmed that best practices dictate that medications ordered to be given with food should be administered within 15-20 minutes of eating to prevent adverse effects and ensure proper absorption. The facility's policy on administering medications also mandates adherence to prescriber orders, including any specified time frames. The failure to follow these guidelines increased the risk of adverse reactions or reduced effectiveness of the medication for Resident 54.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the dietary preferences and intolerances of a resident, identified as Resident 61. The resident, who was cognitively intact and had specific dietary preferences due to gastro-esophageal reflux disease (GERD) and a dislike for tomatoes, was served meals that did not align with her stated preferences. Despite having a preference sheet indicating her dislike for tomatoes, Resident 61 was served jambalaya containing tomatoes, which she could not eat due to her GERD. On another occasion, Resident 61 requested a specific meal of chicken noodle soup and rice due to a toothache, but was instead served a regular diet tray that did not meet her request. The Dietary Supervisor confirmed that the resident had communicated her meal preference earlier in the day, but the kitchen staff failed to provide the correct meal. This miscommunication led to Resident 61 receiving meals that she could not consume, causing frustration and dissatisfaction. The facility's policy and procedure for accommodating resident needs and food preparation were not followed, as the resident's food dislikes were not properly recorded or communicated to the kitchen staff. The Registered Dietician confirmed that the resident's meal ticket should have reflected her dislike for tomatoes, and alternatives should have been offered. The Dietary Supervisor acknowledged the oversight and the impact it had on the resident's dining experience.
Infection Control Failures in Catheter and G-tube Management
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, leading to potential exposure to harmful bacteria and viruses. For Resident 49, the deficiency involved the improper handling of an indwelling catheter drainage bag. The resident's care plan specified that a basin should be placed under the Foley catheter drainage bag to prevent it from touching the floor, as this could lead to urinary tract infections. However, during an observation, the drainage bag was found touching the floor without a basin underneath, contrary to the facility's policy and procedure for catheter care. In the case of Resident 299, the deficiency was related to the failure of a licensed nurse to follow Enhanced Barrier Precautions (EBP) while handling the resident's feeding tube. The nurse administered medications via the G-tube wearing only gloves, without the required gown, despite signage indicating the need for such precautions. The nurse acknowledged the oversight, attributing it to the absence of a PPE cart outside the room, which could lead to cross-contamination and spread of bacteria. Both deficiencies were confirmed through interviews with facility staff, including a CNA, a treatment nurse, and the Director of Nursing, who all acknowledged the importance of following the infection control measures outlined in the residents' care plans and facility policies. The facility's policies clearly indicated the need for these precautions to prevent infections and ensure resident safety.
Visitor Non-Compliance with PPE in Isolation Room
Penalty
Summary
The facility failed to ensure that a visitor for one of the residents adhered to the required personal protective equipment (PPE) protocols while in a contact isolation room. The resident in question was admitted with diagnoses including a urinary tract infection (UTI) and Klebsiella pneumoniae, necessitating contact isolation precautions. Despite the presence of a contact isolation sign indicating the need for an isolation gown and gloves, a family member was observed at the resident's bedside without wearing the required PPE. This oversight was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the importance of PPE in preventing the spread of infectious bacteria. Further interviews with the Infection Preventionist Nurse (IPN) and a review of the facility's policy and procedure on transmission-based precautions highlighted the necessity for visitors to wear gloves and a disposable gown upon entering isolation rooms. The IPN reiterated the critical role of PPE in protecting both the resident and visitors from exposure to bacteria, especially given the resident's compromised immune system. The facility's policy, revised in September 2022, mandates these precautions to prevent the transmission of infections to other residents.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a potential delay in care and increased risk of injury. Resident 2, who was admitted with hemiplegia and hemiparesis following a stroke, was observed with their call light on the floor, out of reach. This resident was cognitively impaired and dependent on staff for various activities of daily living, including toileting and mobility. During an observation, a Certified Nursing Assistant (CNA) confirmed that the call light was not within reach, which is crucial for residents to call for assistance. Similarly, Resident 3, who had hemiparesis and peripheral vascular disease, was observed with their call light on the nightstand, also out of reach. This resident was cognitively impaired and dependent on staff for daily activities. The CNA acknowledged the importance of having the call light within reach to prevent residents from attempting to get out of bed on their own, which could lead to falls. The Director of Nursing emphasized the necessity of having call lights accessible to ensure timely assistance. The facility's policy on the call system was reviewed, highlighting the requirement for residents to have a means to call staff for help.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information at the start of each shift on 11/13/2024, as required by their policy. This deficiency was identified during an observation and interview conducted at the nursing station with the Administrator at 2:01 PM. The Administrator acknowledged that the Daily Nursing Staffing form, which should indicate both projected and actual nursing hours, had not been posted for the morning shift (7 AM - 3 PM) on that day. The Director of Staff Development, responsible for updating and posting this information daily at 9 AM, admitted during an interview at 2:11 PM that she forgot to post the staffing information for the morning shift. The facility's policy, revised in August 2022, mandates the daily posting of nurse staffing data for each shift, including the number of nursing personnel providing direct care to residents. The failure to adhere to this policy resulted in the potential for residents and visitors to be unaware of the nursing hours and the number of nurses working each shift.
Inaccurate COVID-19 Vaccination Records for Staff
Penalty
Summary
The facility failed to maintain accurate records of employee COVID-19 vaccination status, which is a critical component of infection prevention and control. During a review of the facility's National Healthcare Safety Network (NHSN) reporting from January to June 2024, it was found that the facility inaccurately reported 100% COVID-19 vaccination for staff, while in reality, only 30% of employees were vaccinated. The Infection Preventionist Nurse (IPN) confirmed the discrepancy and admitted to not having a current vaccination list for the facility's employees. Further investigation revealed that the facility did not have copies of COVID-19 vaccination cards for specific staff members, including a Licensed Vocational Nurse and a Certified Nursing Assistant. The facility's policy, dated May 2024, mandates that copies of vaccination proof should be kept for both staff and residents. The Administrator acknowledged that the facility should have a list and copies of staff vaccination cards upon hiring, as per their policy. This deficiency in documentation and reporting placed residents and staff at risk for potential COVID-19 infection.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to reasonably accommodate the needs of two residents by not answering their call lights in a timely manner. Resident 1, who was admitted with muscle weakness and left-side hemiplegia, required substantial assistance with daily activities and was frequently incontinent. On one occasion, Resident 1 activated the call light at 7:05 AM but did not receive assistance until 8:30 AM, as confirmed by both the resident and staff interviews. This delay in response left Resident 1 feeling uneasy. Similarly, Resident 2, who was admitted with muscle weakness and abnormal gait, required moderate assistance with daily activities. Resident 2 reported waiting 15 to 20 minutes for the call light to be answered, which caused distress. An observation confirmed that the call light was activated and answered after seven minutes. The Director of Nursing stated that call lights should be answered within five minutes, and the facility's policy also indicated that calls should be answered as soon as possible, but no later than five minutes. Resident Council Minutes from previous months also highlighted ongoing issues with call lights not being answered promptly.
Failure to Ensure Proper Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Ativan, by not having a specific target behavior documented for its use. The resident, who had diagnoses of dementia, anxiety disorder, and panic disorder, was administered Ativan without a physician's order. The Minimum Data Set indicated that the resident had no cognitive impairment and did not exhibit mood or behavior symptoms, yet Ativan was administered for vague panicky feelings without a specific target behavior being identified. On 5/5/2024, the resident received Ativan despite the absence of an active physician's order, as confirmed by a Licensed Vocational Nurse (LVN). The medication was not removed from the medication cart after being discontinued, which posed a risk of it being mistakenly administered. The Pharmacist Consultant noted that the order for Ativan was vague and lacked specific behavior manifestations, which should have been monitored to assess the medication's effectiveness. The Director of Nursing acknowledged that the Ativan order was incomplete and emphasized the importance of specifying target behaviors for monitoring purposes. The facility's policy required that psychotropic medications be clinically indicated and documented in the clinical record, and that medications should not be administered without a physician's order. The failure to adhere to these policies resulted in the administration of Ativan without proper documentation and oversight.
Unnecessary Physical Restraint of Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical restraint. On 4/1/2024 at 3:30 am, two Licensed Vocational Nurses (LVN 1 and LVN 2) tied a resident with a white linen from the waist down to the back of her wheelchair, restricting her movement and preventing her from getting up. This action was taken without attempting less restrictive alternatives, as required by the facility's policy on the use of restraints. The resident, who had diagnoses including cerebrovascular disease, gastrostomy, dysphagia, and anxiety disorder, was unable to follow commands and required moderate assistance with daily activities. The resident also lacked the capacity to understand and make decisions, as indicated in her medical records and assessments. The incident was reported by a Certified Nursing Assistant (CNA1) and confirmed through interviews and video surveillance review by the Director of Nurses (DON) and the Administrator (ADM). The facility's policy on restraints, revised in April 2017, clearly states that physical restraints should not be used without a pre-restraining assessment and review to determine the need for restraints and to explore less restrictive interventions. The DON and ADM acknowledged that the LVNs involved should have tried to reapply the resident's abdominal binder multiple times instead of resorting to tying her with a bedsheet. The facility's surveillance video corroborated the incident, showing the LVNs tying the resident with a white linen and covering it with a resident gown. The facility's policy also specifies that practices preventing resident mobility, such as tucking sheets too tightly or placing a resident in a chair that prevents rising, are considered restraints and are not permitted. The policy emphasizes the need for a thorough assessment to identify underlying causes of problematic symptoms and to determine if less restrictive interventions could be effective.
Failure to Promote Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote dignity and respect for five residents, leading to several deficiencies. Resident 16 was observed with food on her clothes, face, and hands, indicating a lack of assistance during meals. Despite the facility's policy requiring residents to be treated with dignity and respect, Resident 16 was not provided with a bib or adequate supervision during meals, as confirmed by both family members and staff. This lack of assistance could potentially affect the resident's dignity and nutritional intake. Resident 85 was found sitting in bed wearing an incontinent brief with the privacy curtain open, exposing his lower extremities. This observation was confirmed by multiple staff members, who acknowledged that the resident's dignity was compromised. The facility's policy mandates maintaining resident privacy, but this was not adhered to, leaving Resident 85 exposed and undignified. Resident 89 was found with food debris on his shirt and dried white liquid on his chin after breakfast, indicating inadequate post-meal care. Staff members confirmed that Resident 89, who has severe cognitive impairment and poor vision, should have been cleaned after eating. Additionally, Resident 72's personal space was not protected as Resident 90 repeatedly grabbed his food and foot, causing distress. Lastly, Resident 90 was assisted with feeding by a staff member standing over him, which is against the facility's policy of providing meal assistance at eye level to ensure dignity and comfort.
Failure to Follow Advance Directives Policy
Penalty
Summary
The facility failed to follow its Advance Directives policy for three residents, leading to deficiencies in documenting and maintaining advance directives. Resident 44 did not have documented evidence of being informed about the choice to complete an advance directive. Despite having the capacity to understand and make decisions, there was no advance directives acknowledgment form in the resident's chart. The Director of Nursing confirmed that the form should have been completed to ensure staff knew how to manage the resident during emergencies, as per the facility's policy revised in September 2022. Resident 68's advance directive was not maintained in the resident's chart. The resident, who had severe cognitive impairment due to dementia and Alzheimer's disease, had a Physician Orders for Life-Sustaining Treatment (POLST) indicating a Do Not Attempt Resuscitation (DNR) status. However, the section for advance directive information was left unchecked, and the Medical Record Assistance confirmed that the medical record did not contain a copy of the resident's advance directive. Similarly, Resident 251's advance directive was not maintained in the resident's chart. The resident, who had severe cognitive impairment and schizophrenia, had a POLST indicating a DNR status and an advance directive dated 12/21/09. However, the Medical Record Assistance confirmed that the medical record did not contain a copy of the advance directive. Both the Licensed Vocational Nurse and the Social Services Director stated that the resident's advance directives should be obtained upon admission and maintained in the medical record to ensure that the resident's wishes for medical treatment are known and followed.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop an individualized resident-centered care plan for three residents, leading to unmet needs and potential health risks. Resident 58 did not have a care plan addressing their behavior of not wanting to share a communal restroom, which led to conflicts with another resident. Despite being moderately cognitively impaired and requiring assistance with daily activities, Resident 58's behavior was not managed, causing distress to both residents sharing the restroom. Interviews with staff and the Director of Nursing confirmed the absence of a care plan for this behavior, despite its recurrence and impact on other residents. Resident 37, who was on antibiotic medication for cellulitis and had multiple health issues including a right below-the-knee amputation and end-stage renal disease, did not have a comprehensive care plan for the use of intravenous antibiotic therapy. The care plan lacked goals and interventions to monitor for potential infections and complications related to the IV access and medication administration. The Director of Nursing acknowledged the oversight, stating that a care plan should have been formulated to monitor the medication's side effects and effectiveness. Resident 79, who was on anticoagulant therapy for peripheral vascular disease, did not have their care plan implemented to monitor for signs and symptoms of bleeding. Despite having a care plan that outlined the need to monitor for bleeding, there was no documented evidence that this intervention was carried out. The Minimum Data Set Nurse confirmed the lack of implementation, emphasizing the importance of monitoring to ensure the medication's effectiveness and to avoid potential side effects. The facility's policy on comprehensive, person-centered care plans was not adhered to in these cases, leading to significant deficiencies in resident care.
Failure to Provide Consistent Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for three residents, as ordered by their physicians. Resident 64, who had severe cognitive impairment and multiple physical limitations, did not receive the prescribed restorative nursing services (RNA) for passive range of motion (PROM) and splint application on numerous occasions. Observations confirmed that the resident was often without the necessary splints, and interviews with staff revealed that RNA services were frequently missed due to staffing shortages, with RNAs working as CNAs instead of providing the required restorative care. Resident 63, who also had severe cognitive impairment and physical limitations, similarly did not receive the prescribed RNA services consistently. The resident's care plan included the application of a left resting hand and elbow splint, but observations showed that these were not applied regularly. Staff interviews indicated that the splints were not used as required, and the RNA services were not documented or performed as ordered. Resident 15, with severe cognitive impairment and contractures, was also affected by the facility's failure to provide consistent RNA services. The resident's care plan required the application of bilateral elbow and hand splints, but observations and staff interviews confirmed that these were not applied regularly. The splints were found stored improperly, and the RNA services were not performed as ordered. The facility's policies on resident mobility and restorative nursing services were not followed, leading to a risk of further decline in the residents' physical functions.
Failure to Maintain Proper Head of Bed Elevation During Enteral Feedings
Penalty
Summary
The facility failed to ensure that the head of bed (HOB) was elevated above 30 to 45 degrees during enteral feedings for two residents, Resident 62 and Resident 68. Resident 62, who was diagnosed with dysphagia and gastro-esophageal reflux disease, was observed receiving gastrostomy tube (GT) feeding with the HOB at approximately 20 degrees, contrary to the physician's order for 30-45 degrees elevation. Multiple staff members, including a Licensed Vocational Nurse (LVN) and an Infection Prevention Nurse (IPN), failed to adjust the HOB to the required elevation during their checks. Resident 62 had severe cognitive impairment and was dependent on staff for daily activities, further emphasizing the need for proper care during feedings to prevent aspiration risks. The facility's policy also mandated a 30-45 degree elevation during tube feedings, which was not adhered to in this case. Similarly, Resident 68, who had diagnoses including attention to gastrostomy, Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure with hypoxia, dementia, and Alzheimer's disease, was observed with the HOB below the required 30-45 degrees during GT feeding. A Registered Nurse (RN) confirmed that the HOB was too low and should have been elevated to prevent aspiration. The Director of Nursing (DON) acknowledged that the failure to maintain the correct HOB elevation during GT feedings put residents at risk for aspiration, and it was the responsibility of licensed nurses to ensure compliance with this requirement. The facility's policy, revised in March 2023, also stipulated the need for a 30-45 degree HOB elevation during tube feedings, which was not followed in these instances.
Failure to Provide Necessary Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, leading to potential health risks. For Resident 36, the oxygen humidifier was not changed per the physician's order, and the oxygen humidifier dated 3/4/24 was still in use on 3/12/24. Additionally, there was no visible oxygen signage by Resident 36's door, which could pose a fire hazard. The Licensed Vocational Nurse (LVN) confirmed that the humidifier was not changed as required and acknowledged the absence of proper labeling and signage. For Resident 40, the facility did not change the humidifier and oxygen tubing every seven days as per policy. Observations on 3/12/24 and 3/13/24 revealed that the humidifier and oxygen tubing were not labeled with the date of change. The LVN confirmed that the humidifier and oxygen tubing were not dated, and only the storage bag was labeled. The Director of Nursing (DON) stated that the humidifiers and oxygen tubing should be labeled and changed weekly to prevent infection. The facility's policies and procedures were not followed, as indicated by the lack of proper labeling and timely changes of respiratory equipment. The absence of visible oxygen signage for both residents further demonstrated non-compliance with safety protocols. These deficiencies were confirmed through observations, interviews, and record reviews, highlighting the facility's failure to adhere to established respiratory care standards.
Failure to Provide Dialysis Emergency Kits and Alert Signs
Penalty
Summary
The facility failed to ensure that residents who received dialysis care had the necessary emergency kits and alert signs at their bedside. Specifically, for Residents 5, 14, and 20, the facility did not provide dialysis emergency kits or post alert signs indicating precautions for the dialysis site access. This deficiency was observed during multiple instances and confirmed by staff interviews and record reviews. Resident 20, who was moderately cognitively intact and required assistance with various activities of daily living, did not have an emergency kit at the bedside. Licensed Vocational Nurse (LVN) 7 confirmed the absence of the kit and acknowledged its necessity in case of emergencies such as bleeding. Similarly, Resident 14, who had severe cognitive impairment and was dependent on renal dialysis, also lacked an emergency kit and an alert sign. LVN 10 and LVN 6 both confirmed the absence of these critical items and emphasized their importance in preventing complications. Resident 5, who had severe cognitive impairment and was dependent on dialysis, was also found without an emergency kit and alert sign at the bedside. Multiple observations confirmed this deficiency, and staff members, including LVN 8 and the Director of Nursing (DON), acknowledged the need for these items. The facility's policies and procedures, which were reviewed, indicated that residents with end-stage renal disease should be cared for according to recognized standards, including the provision of emergency kits and alert signs at the bedside.
Failure to Provide Social Services and Follow-Up Care
Penalty
Summary
The facility failed to provide necessary social services for two residents, leading to delays in care and services. Resident 70, who has dementia and glaucoma, misplaced her hearing aids on 2/27/24. Despite the facility's policy requiring the reporting of lost items valued over $100 to law enforcement, this was not done. Interviews with staff confirmed the hearing aids were missing, and the Social Services Director acknowledged the oversight. The facility's policies on caring for hearing-impaired residents and theft and loss were not followed, resulting in a lack of communication tools for Resident 70. Resident 79, diagnosed with dysphagia and schizophrenia, required new dentures as indicated in a dental care record dated 7/6/23. Despite a physician's order for a dental consult and treatment, the resident did not receive the necessary follow-up care. The Director of Nursing incorrectly believed that the resident's responsible party was handling dental appointments, which was contradicted by the responsible party. The Social Services Assistant confirmed that Resident 79 had not received dental care follow-up since 7/6/23, contrary to the facility's policy requiring dental services every three to six months. The facility's failure to adhere to its policies and procedures for both residents resulted in significant delays in addressing their needs. The Social Services department did not facilitate the necessary follow-ups for Resident 70's hearing aids and Resident 79's dental care, leading to potential delays in care and services. The deficiencies highlight lapses in communication and adherence to established protocols within the facility.
Failure to Label and Discard Expired Food
Penalty
Summary
The facility failed to label foods in the kitchen with 'use by' dates and did not discard expired food as per the facility's policy and procedure. During an observation and interview with the Dietary Trayline (DT), it was noted that several food items in the kitchen's refrigerators were not labeled with 'use by' dates, including containers of cut-up watermelon, Jello, egg salad, lemon juice, and apple sauce. The DT confirmed that these items should have been labeled and discarded when expired. Additionally, two cartons of cranberry juice in the dry storage room were found to be expired and should have been thrown away. The Dietary Supervisor (DS) confirmed that food items should be discarded by the 'use by' date, as it indicates the food's expiration date. The facility's policies on refrigerator/freezer storage and storage of canned and dry goods were reviewed, indicating that all items should be properly dated and labeled, and no expired food should be in stock. However, the facility did not adhere to these policies, leading to the potential risk of pathogen exposure to residents.
Failure to Follow Antibiotic Stewardship Program Protocols
Penalty
Summary
The facility failed to ensure the antibiotic stewardship program protocols for prescribing the appropriate antibiotics were followed for eight of ten sampled residents. Specifically, the facility did not complete the Surveillance Data Collection form for six residents who were receiving antibiotics in March 2024. Additionally, the facility did not follow the surveillance data collection form prior to prescribing antibiotics for two residents in February 2024. This failure had the potential to result in the prescription of inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms. Resident 73, who was admitted with diagnoses including glaucoma and hemiplegia, was prescribed Moxifloxacin without the completion of the Surveillance Data Collection form. Similarly, Resident 64, diagnosed with cataract and dementia, was prescribed Erythromycin Ophthalmic Ointment without the necessary surveillance documentation. Other residents, including Resident 29 with cataract and macular degeneration, and Resident 87 with glaucoma and blindness, were also prescribed antibiotics without proper surveillance data collection. During interviews and record reviews, it was revealed that the facility's Infection Preventionist (IP) Nurse acknowledged the lack of surveillance for residents on antibiotic therapy for March 2024. The IP Nurse also confirmed that both criteria must be met for antibiotic therapy to be initiated, and there was no documentation indicating that the doctor was notified when Residents 65 and 11 only met one criterion on the surveillance data form. The facility's policies and procedures for infection prevention and control, as well as the job description for the Infection Control Preventionist, were not adhered to, leading to this deficiency.
Failure to Disinfect Laundry Washer Handles
Penalty
Summary
The facility failed to disinfect the handles of two laundry washers with an EPA-approved disinfectant solution as required by their policy. During an observation, a laundry staff member was seen loading soiled clothes into Washer 1 and unloading clean clothes from Washer 2 without disinfecting the handles of either machine. The staff member admitted to not knowing that the handles needed to be disinfected, acknowledging the potential for contamination of clean laundry. The Infection Preventionist confirmed that the handles should have been disinfected to prevent the spread of infection. A review of the facility's policies indicated that all machines should be wiped down with a disinfection solution after use and that soiled textiles should be handled with minimal agitation to avoid contamination. The failure to follow these procedures had the potential to spread infection within the facility.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for one of the sampled residents, who experienced severe weight loss greater than 5% in one month. Resident 40, who had multiple diagnoses including type 2 diabetes mellitus with chronic kidney disease and dementia, was not reported to the physician despite a documented weight loss of 17 pounds over a month. The resident's weight dropped from 121 pounds to 104 pounds, indicating a severe weight loss of 14.05%. The facility's policy required that the physician be notified of such significant weight changes, but this was not done in a timely manner. The report details that the licensed nurses were aware of the resident's weight loss but failed to notify the physician on the same day as required. The Licensed Vocational Nurse (LVN) acknowledged the importance of notifying the physician to ensure the resident's health was not declining and to ensure adequate nutrient intake. However, the physician was only notified two days after the severe weight loss was documented. Additionally, the Dietary Supervisor admitted to documenting that the physician and family were notified without actually witnessing the notification. The Director of Nursing (DON) confirmed that the licensed nurses should have contacted the physician to address the significant weight loss, which was defined as 5% in 30 days. A review of the facility's policies indicated that significant weight changes should be reported to the physician within 24 hours. Despite these policies, the physician was not notified of the resident's 17-pound weight loss until 10 days later, highlighting a clear deficiency in following the established protocols for weight management and physician notification.
Failure to Ensure Accurate Resident Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of Resident 19's active diagnoses, specifically omitting schizophrenia from the Minimum Data Set (MDS) assessment. Resident 19 was readmitted to the facility with diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and paranoid schizophrenia. However, the MDS assessment dated 3/4/24 did not list schizophrenia as an active diagnosis, despite it being present in the resident's Admission Record. This discrepancy was confirmed during interviews with the Medical Record Assistant and the Minimum Data Set Nurse who completed the assessment. The Medical Record Assistant acknowledged that an inaccurate assessment would prevent staff from providing appropriate care and medication for the resident's needs. Further interviews revealed that the Minimum Data Set Nurse who completed the assessment was unable to articulate the impact of the inaccurate diagnosis on the resident's quality of care. Additionally, a Registered Nurse confirmed that without the schizophrenia diagnosis on the MDS assessment, no care plan or interventions for schizophrenia would be developed, resulting in the resident not receiving necessary treatments. The facility's policy on certifying the accuracy of resident assessments, which requires all persons completing any portion of the MDS to attest to its accuracy, was not adhered to in this case.
Failure to Provide Necessary Assistance and Communication Tools
Penalty
Summary
The facility failed to ensure that Resident 4 received the necessary assistance with eating, as indicated in their care plan. Resident 4, who has diagnoses including dementia and anorexia, was observed eating while lying down without supervision or assistance. Both the Activities Director and a Certified Nursing Assistant confirmed that this was inappropriate and posed a choking hazard. The facility's policy on assistance with meals and safety and supervision of residents was not followed, as Resident 4 was not provided the required help with eating and was left in a potentially dangerous position while consuming food. Resident 37, who has diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, was not provided with a communication board as required by their care plan. Despite the staff speaking the same language as Resident 37, there were still communication barriers that led to frustration and unmet needs, such as receiving cold soup. Observations confirmed that the communication board was not present in Resident 37's room, and the communication binder available was for the roommate and not in Resident 37's preferred language. The facility's policy on accommodating residents' needs was not adhered to, resulting in communication difficulties for Resident 37. These deficiencies indicate that the facility did not provide the necessary treatment and services to maintain or improve the level of assistance needed with activities of daily living for Residents 4 and 37. The lack of proper assistance and communication tools had the potential to negatively impact the functional abilities and overall well-being of these residents.
Failure to Provide Audiology and ENT Services
Penalty
Summary
The facility failed to provide necessary audiology and ENT services for a resident with hearing loss, as per the physician's orders. Resident 20, who has a history of blindness and dysphagia, was admitted and readmitted to the facility with a diagnosis indicating the need for hearing-related services. Despite a physician's order dated 1/24/24 for audiology consults and ENT follow-up treatment, the resident had not received these services. The last ENT consultation was in 2022, and the resident was due for a follow-up in 2023, which did not occur. The resident reported difficulty hearing and did not use hearing aids, and there was no care plan addressing the resident's hearing loss. Interviews with the Director of Nursing and the Social Services Director confirmed that the resident should have been referred to an ENT specialist and that the resident's hearing loss was not included in the care plan. The facility's policy on caring for hearing-impaired residents requires observation for increased hearing loss and addressing hearing problems in the care plan, which was not followed in this case. The Social Services Job Description also mandates facilitating identified problems, including communication issues, which was not adequately done for Resident 20.
Failure to Implement Correct LAL Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement appropriate treatment for the prevention of pressure ulcers by not ensuring that the low air loss (LAL) mattress was set correctly for Resident 48. Resident 48, who was admitted with an unstageable pressure injury and other medical conditions, was observed with the LAL mattress set at 240 mmHg, which was not appropriate for the resident's weight of 187 pounds. The Licensed Vocational Nurse (LVN) confirmed that the LAL mattress should have been set at 160 or 200 mmHg based on the resident's weight, and the Registered Nurse (RN) acknowledged that an incorrect setting would make the mattress too firm, defeating its purpose for wound care and management. The facility's policy and procedure for support surfaces and prevention of pressure injuries indicated that support surfaces should be modifiable and selected based on the resident's risk factors. Despite these guidelines, the incorrect setting of the LAL mattress was observed multiple times, and the staff confirmed that the setting was not adjusted according to the resident's weight. This failure to adhere to the facility's policy and procedure had the potential to place Resident 48 at risk for the progression of the pressure ulcer.
Failure to Follow Pharmacist's Recommendation for Carvedilol Administration
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation to include the manufacturer's recommendation for the use of Carvedilol for one of the sampled residents, Resident 20. The pharmacist had recommended that Carvedilol be administered with food to ensure proper absorption and minimize side effects. However, this recommendation was not followed, as confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) during interviews. The medication order for Carvedilol did not include the instruction to take it with food, despite the pharmacist's clear recommendation in the Medication Regimen Review (MMR) dated 1/19/24. Resident 20 was readmitted to the facility with diagnoses including hypertension and end-stage renal disease. The resident was prescribed Carvedilol 3.125 mg to be taken twice daily. The failure to follow the pharmacist's recommendation had the potential to cause fast absorption of the medication, leading to side effects such as dizziness or fainting when standing up. Both the LVN and the DON acknowledged that the MMR recommendation should have been followed to ensure the resident was receiving the medication correctly.
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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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