Los Feliz Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3002 Rowena Avenue, Los Angeles, California 90039
- CMS Provider Number
- 056380
- Inspections on file
- 47
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Los Feliz Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with multiple medical conditions and high assistance needs developed diarrhea and later tested positive for C. difficile, prompting the decision to move the resident to a private room under contact isolation. An LVN documented in the electronic record that the resident had been placed in a private room earlier in the day, even though the room was still being cleaned and the actual transfer did not occur until later, as corroborated by a CNA. The DON stated that nurses must only chart what has actually occurred, and facility policy requires that events be documented as they happen and never in advance, making this entry an inaccurate medical record.
A resident with diabetes and other complex conditions refused a fasting blood sugar check and later had a critically high blood glucose reading. Staff did not notify the physician as required by orders and facility policy, and documentation of the refusal and missed insulin dose was lacking. The physician was only informed after the resident became unresponsive and was being transferred to the hospital.
A resident with diabetes and other complex conditions experienced critically high blood glucose and hypotension, but nursing staff did not notify the physician as required by orders and facility policy. Instead, 911 was called and the physician was only notified after the resident was being transported to the hospital. The resident also missed 14 hours of prescribed tube feeding. These failures resulted in delayed care and the resident's transfer to an acute care hospital with serious complications.
A resident dependent on enteral feeding did not receive the prescribed Glucerna 1.5 regimen due to a failure to initiate the feeding as ordered. Despite having the necessary supplies and physician orders, staff did not start the feeding, resulting in the resident missing 14 hours and 770 ml of nutrition. Facility policy required feedings to be administered as ordered, but this was not followed.
A resident with diabetes and other complex conditions did not receive a scheduled insulin dose after refusing a fasting blood sugar check, despite prior blood sugar readings indicating the medication should have been given. Staff did not obtain an alternative blood sugar measurement at the scheduled time, resulting in missed medication administration and subsequent deterioration in the resident's condition.
A resident with multiple complex medical conditions did not have accurate and complete clinical records due to nursing staff failing to document required progress notes when medications were not administered and not accurately updating the MAR after the resident was discharged to a hospital. The DON and involved LVNs confirmed that documentation was incomplete, which did not meet professional standards and facility policy.
A resident's medical record was incomplete at discharge, as the RN did not complete or sign the Discharge Planning Review Form, and the resident's refusal to sign was not documented. LPNs also failed to document the level of care provided and the resident's health status at discharge, resulting in missing required information in the progress notes.
A resident with severe cognitive impairment and multiple diagnoses was exposed during a shower when the privacy curtain was not fully closed, as observed by staff. Facility policy requires staff to maintain resident privacy during personal care, but this was not followed, resulting in a lapse in dignity and privacy.
A resident with a history of CVA, epilepsy, depression, and hemiplegia, who required significant assistance with daily activities, was found to have their call light placed out of reach. Staff confirmed the call light should have been accessible, as required by the care plan and facility policy, but it was left at the top of the mattress, making it inaccessible for the resident to request help.
A resident with multiple medical conditions and moderate cognitive impairment did not receive necessary transportation to a scheduled pulmonology appointment due to the facility's lack of advance planning and absence of a transportation policy. The Social Services Director did not arrange transportation ahead of time, resulting in no wheelchair-accessible transport being available on the day of the appointment, and the DON confirmed the lack of procedures for such arrangements.
A resident with multiple medical conditions and moderate cognitive impairment had a scheduled pulmonology appointment, but the facility failed to document transportation arrangements and whether the appointment was completed. The absence of this documentation was confirmed by the Social Services Director and was not in accordance with facility policy or professional standards.
The facility did not reconcile or maintain accountability logs for six eKITs containing controlled medications across three medication rooms, and failed to ensure the availability of tramadol for a resident with a physician's order for pain management. As a result, a resident with a history of spinal conditions did not receive prescribed tramadol for moderate to severe pain, and staff confirmed that required shift-to-shift reconciliation of controlled substances was not performed.
Several residents with cognitive and physical impairments experienced deficiencies in their living environment, including a bed control cord with exposed wires, a broken baseboard with exposed nails, and floor mats in disrepair. Staff were aware of these issues but did not promptly report them to maintenance, resulting in unsafe and non-homelike conditions contrary to facility policy.
Several residents were subjected to physical restraints, such as pillows tightly tucked under fitted sheets and the use of bolsters or bed placement against the wall, without proper physician orders, informed consent, restraint assessments, or care plan documentation. These actions restricted residents' freedom of movement and were implemented for staff convenience or safety without following required protocols.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents receiving insulin therapy, despite physician orders and facility policy requiring site rotation. Documentation showed repeated use of the same injection areas over multiple days, and staff interviews confirmed that proper rotation was not consistently performed.
Surveyors found that multiple residents were exposed to accident hazards due to improper placement of heavy objects on fall mats, uncovered electrical outlets, broken baseboards with exposed nails, unsecured smoking materials, and medications left at bedside. Staff interviews and direct observations confirmed that these actions were not in accordance with facility policies, and several residents had cognitive or physical impairments that increased their vulnerability to these hazards.
A resident with hemiplegia and high fall risk was found using padded bilateral upper bedrails without a physician's order, informed consent, or a care plan, despite facility policy requiring these steps. Staff confirmed the bedrails were used for mobility and fall prevention, but records lacked necessary documentation and the only assessment recommended against their use.
Two residents experienced medication errors when an LPN failed to administer a prescribed pain medication due to unavailability and gave a multivitamin with minerals instead of the ordered formulation. These actions resulted in a medication error rate above 5%, as confirmed by the DON and facility records.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by prescriber orders and facility policy, resulting in repeated administration in the same areas. This failure was confirmed by facility leadership and documented in medication administration records, constituting significant medication errors.
Surveyors found that kitchen staff failed to maintain sanitary conditions by not wiping down sticky containers of thickened lemon water and almond milk, not labeling an opened container of apple juice with the date it was opened, and leaving a bottle of brown coloring with dried drippings. The Dietary Supervisor and DON confirmed these actions were not in line with facility policy requiring proper labeling and cleaning of food containers.
Staff failed to consistently label and date food items brought in by family or visitors and stored in the resident-designated refrigerator, including condiments such as ranch dressing, mayonnaise, and salsa. Interviews with dietary, nursing, and administrative staff confirmed that the facility's policy requires labeling with the resident's name and date, and timely disposal, but these procedures were not followed, resulting in unlabeled and potentially expired food being stored.
Staff failed to follow infection control protocols by placing a resident's personal items on the floor, not labeling a urinal bottle, leaving mobile linen carts open in hallways, and using permeable covers on linen carts. These actions resulted in potential contamination of resident care items and clean linens, contrary to facility policy and infection prevention standards.
A resident with multiple diagnoses was given seven medications by an LVN who did not inform the resident of the medication names or their purposes prior to administration. The LVN, unable to communicate in the resident's preferred language, also failed to request a translator as required by facility policy. This resulted in the resident not being fully informed about their care and not having the opportunity to make choices regarding their medication regimen.
A resident with diabetes, a foot ulcer, and limited mobility was found to have their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Staff interviews confirmed the expectation that call lights remain within reach, and the deficiency was observed during a survey.
A resident with hemiplegia and high fall risk had their bed placed against the wall as a restraint without a corresponding care plan or physician's order. Facility staff confirmed that this intervention was not documented in the care plan, leading to potential miscommunication among the IDT and failure to meet policy requirements for comprehensive, person-centered care planning.
A resident with dementia and major depressive disorder, who was dependent on staff and valued participation in religious services, was not consistently informed about or brought to these services. Staff interviews revealed gaps in communication and documentation, and the facility had not implemented its policy for tracking activity attendance, resulting in the resident missing preferred activities and incomplete records.
Two residents were transferred to the hospital without proper documentation of their change in condition, as required by facility policy. In both cases, essential forms and details such as SBAR/Change of Condition, vital signs, and notifications to providers and representatives were missing or incomplete, resulting in a lack of clear communication about the residents' status and care prior to transfer.
A resident with an indwelling urinary catheter was found to have a loop in the catheter tubing, preventing free urine flow into the drainage bag. Staff and the DON confirmed that catheter tubing should be kept free of kinks or loops, in accordance with facility policy and standard practice. The resident had a history of obstructive uropathy and required significant assistance with daily living activities.
A resident with a gastrostomy tube, severe cognitive impairment, and total dependence on staff was found to have a medication syringe that was not properly rinsed after use, as required by physician orders, care plan, and manufacturer guidelines. The syringe was observed with residual liquid and powder, and the ADON confirmed this failure to rinse could lead to GI complications.
A resident with a midline catheter was found with a loose, soiled dressing that was not labeled with the date of the last change, despite facility policy requiring such labeling. Nursing leadership confirmed that the lack of a date could prevent staff from knowing when the dressing was last changed, which did not meet professional standards for IV care.
A resident with ESRD who required regular hemodialysis did not receive timely physician follow-up after missing a dialysis session, and a dialysis emergency kit was not available at the bedside as required. Facility staff confirmed the absence of the kit and lack of physician notification, despite policies mandating these actions for dialysis care.
Staff failed to label an opened multi-dose epoetin alfa vial with the date of first use and expiration, contrary to manufacturer and facility policy, and did not remove it from use. Additionally, an IV antibiotic prepared from the emergency kit was not labeled with the resident's name or rate of administration. These deficiencies were confirmed by nursing staff and the DON, and were identified through observation and record review.
A resident with moderate cognitive impairment and multiple medical conditions experienced a toothache that was verbally reported by a family member, but the Social Services Director did not document the complaint or ensure a timely, specific dental referral. When the resident was seen by the dentist, the dental record lacked the chief complaint, and there was no follow-up with the family to confirm resolution, resulting in a failure to address the dental issue as required by facility policy.
A resident with a terminal prognosis and multiple complex diagnoses was admitted to hospice care, but the facility failed to assign a qualified hospice coordinator to oversee and coordinate care between hospice and facility staff. The Medical Records Director, who was designated as the hospice coordinator, was only responsible for record-keeping and was not involved in care coordination or the interdisciplinary team. This resulted in incomplete hospice documentation and a lack of proper coordination of hospice services for the resident.
A resident with multiple health conditions was found to have a bed control cord with frayed and exposed wires, which had previously been inadequately repaired with tape. Staff observed the hazard but did not report it immediately, and maintenance staff acknowledged that the repair did not meet facility policy or equipment manual standards. Facility policies require immediate reporting and proper repair of such hazards to maintain a safe environment.
Two residents' activity records were inaccurately documented when activity assistants used another staff member's login to chart attendance and services, resulting in records showing staff signatures on days they were not present. This practice was confirmed by staff interviews and was not in accordance with facility policy, which requires only authorized staff to document in medical records and prohibits signing for others.
A resident's patio was cluttered with facility and residents' belongings, including trash bags, mattresses, and a wheelchair covered by a tarp, affecting their homelike environment. The resident, with conditions like rheumatoid arthritis and major depressive disorder, expressed concerns about potential rodents and limited space. The Environmental Director and DON acknowledged the issue, which violated the facility's policy for a safe and comfortable environment.
A resident's medical records were inaccurately documented when a complaint of a possible infection on a dialysis access port was recorded with the wrong date, leading to an incorrect timeline of events. The error was acknowledged as a typographical mistake by an LVN, highlighting a failure to ensure accurate documentation as per the facility's policy.
The facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating their needs. One resident with muscle weakness had the call light placed on the side of his contracted arm, making it inaccessible. Another resident with impaired vision and cognition had the call light on the floor, while a third resident's call light was positioned at the head of the bed, out of reach. A fourth resident with dementia had the call light hanging on the bed rail, touching the floor. The facility's policy to keep call cords within reach was not followed.
Two residents in the facility were subjected to the use of bed rails and bed placement against the wall without proper assessment, physician orders, or informed consent. Both residents had the capacity to understand and make decisions, yet the facility failed to document safety assessments or educate the residents or their representatives on the risks and benefits of such restraints. This oversight violated the facility's policy, which mandates that restraints be used only when necessary and with appropriate documentation.
The facility failed to develop comprehensive care plans for residents, including those using physical restraints and receiving medications like vancomycin and Risperdal. This led to inadequate monitoring and documentation, potentially compromising resident safety and care.
Three residents in the facility received insulin injections without proper site rotation, leading to potential adverse effects. Despite orders to rotate injection sites, the nursing staff repeatedly administered insulin in the same areas, such as the arms and abdomen, for residents with type 2 diabetes mellitus. This deficiency was confirmed through record reviews and staff interviews, highlighting the importance of site rotation to prevent complications like lipodystrophy.
The facility failed to prevent accidents and hazards for three residents. A resident who smoked had cigarettes at his bedside without proper assessment of smoking risk, potentially leading to fire hazards. Another resident was left with her bed in a high position, increasing fall risk. A third resident with cognitive and visual impairments was not accurately assessed for elopement risk, despite a history of attempted elopement and wearing a wander guard.
The facility failed to manage enteral feeding properly for three residents, leading to deficiencies in labeling and administering feeding and hydration. A resident's water flush bag was mislabeled with an incorrect infusion rate, another resident's irrigation syringe lacked proper labeling, and a third resident's tube feeding formula was not labeled with the rate and time. These oversights were confirmed by staff and highlighted the importance of adhering to physician orders and facility policies to ensure proper nutrition and infection control.
A facility failed to document post-dialysis assessments and retain written documentation from the dialysis center for a resident with end-stage renal disease. The resident's care plan required monitoring for complications, but assessments were not consistently documented, and important records were shredded instead of being saved in the medical record. This failure was acknowledged by the DON and contradicted the facility's policies and contractual obligations.
The facility failed to ensure the safe use of bed rails for two residents, leading to deficiencies in care. Both residents had bed rails up without a physician's order or informed consent, and there was no documentation of education on the risks and benefits. The facility's policy required assessments and consents, which were not followed, resulting in potential risks of harm and restricted movement.
A facility failed to account for doses of controlled substances for three residents and did not document the disposition of non-controlled medications in three medication rooms. LVNs admitted to administering medications without proper documentation, violating facility policy. The residents involved had significant medical histories, and the lack of documentation could have led to medication errors.
A resident was prescribed Risperdal for delusions without a specific target behavior or proper monitoring for side effects and alternative therapies. The facility's records lacked documentation for occurrences of delusions and adverse effects, and there was no follow-up from the physician on the pharmacy consultant's note about the lack of an allowable diagnosis. Staff interviews confirmed these deficiencies, which were contrary to the facility's policy on psychoactive drug management.
The facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite clear orders to rotate sites to prevent complications, insulin was repeatedly administered in the same areas. Interviews with nursing staff confirmed the oversight, classifying it as a medication error due to non-compliance with physician's orders and professional standards.
The facility did not comply with its policy to record medication refrigerator temperatures twice daily, as observed in two medication rooms. From early to late June, temperature logs showed checks only once daily during the night shift. Both an RN and an LVN confirmed this practice, which contradicted the facility's policy and CDC guidelines. The DON acknowledged the lapse, noting the risk to vaccine efficacy and potency.
Inaccurate Advance Documentation of Isolation Room Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical record was accurately documented in accordance with facility policy. The resident had a history that included cerebral ischemia, spinal stenosis, and paroxysmal atrial fibrillation, and had been recently re-admitted after treatment for a urinary tract infection. An MDS assessment indicated the resident required maximal assistance with eating, personal hygiene, and upper body dressing, and was dependent for toileting hygiene and bathing. These details establish the resident’s clinical status and functional dependence at the time of the events. On the day in question, the resident experienced several episodes of diarrhea, and a stool sample was collected and later tested positive for C. difficile. Following receipt of the positive test result, nursing staff determined the resident needed to be moved to a private room and placed on contact isolation. LVN 1 stated that the new private room still needed to be cleaned before the resident could be transferred and reported that the actual transfer occurred around midday. CNA 1 similarly recalled that housekeeping had to clean the new room first and that the transfer occurred shortly before CNA 1’s lunch break at approximately 11:30 a.m. However, review of the electronic medical record showed that an Infection Note dated the same day was entered at 9:07 a.m., indicating that the resident had already been placed in a private room. When questioned, LVN 1 acknowledged that the note was likely completed before the transfer actually occurred and that the documentation was inaccurate at the time it was entered. The DON confirmed that licensed nurses are expected to chart what they have actually done and not to document events in advance, referencing the facility’s policy on Completion & Correction, which states that entries must be recorded as events occur and that an event is never to be documented before it happens. This sequence of actions resulted in an inaccurate medical record for the resident.
Failure to Notify Physician of Critical Blood Sugar Refusal and Elevated Glucose
Penalty
Summary
The facility failed to notify the medical doctor when a resident with multiple complex diagnoses, including type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease, refused a fasting blood sugar (FSBS) check and subsequently had a critically elevated blood glucose reading. The resident, who lacked capacity to make healthcare decisions, was admitted with orders for regular FSBS monitoring and specific instructions to notify the physician if blood sugar exceeded 250 mg/dL. On the morning in question, the resident refused the FSBS at 6 a.m., and this refusal was not communicated to the physician as required by both facility policy and physician orders. Later that day, the resident was found to have a blood glucose level of 379 mg/dL and was noted to be difficult to arouse, with vital signs indicating hypotension. Despite the elevated blood sugar and the physician order to notify for readings above 250 mg/dL, staff did not contact the physician at that time. Instead, emergency services were called when the resident became unresponsive, and the physician was only notified after the resident was being transported to the hospital. Documentation was lacking regarding both the refusal of the FSBS and the missed insulin dose, and there was no evidence that the physician was informed of these events in a timely manner. Interviews with nursing staff and facility leadership confirmed that the physician should have been notified immediately of the resident's refusal and the subsequent high blood sugar, as per facility policy and standard practice. Staff acknowledged that failure to notify the physician could result in a delay of care. The facility's policies on medication administration, diabetic care, and blood glucose monitoring all require prompt physician notification for refusals and for blood sugar readings outside specified parameters, but these procedures were not followed in this case.
Failure to Notify Physician and Administer Care for Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when nursing staff failed to follow physician orders and facility policy regarding the management of a resident with type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease. The resident was admitted with orders for blood glucose monitoring every six hours, with instructions to notify the physician if blood sugar exceeded 250 mg/dL. On the day in question, the resident's blood sugar was found to be 379 mg/dL, and later, upon transfer to the hospital, was recorded as greater than 500 mg/dL, with laboratory results showing a glucose level of 1,443 mg/dL. Despite these critical findings, the nursing staff did not notify the physician as required by the orders and facility policy. Interviews with the LVN and RN involved revealed that neither contacted the physician when the resident's blood sugar was elevated and the resident became unresponsive with hypotension. Instead, they called 911 and only notified the physician after the resident was already being transported to the hospital. The staff acknowledged that physician notification could have resulted in additional orders, such as insulin or fluids, but this step was omitted. The facility's policies on medication administration, diabetic care, and blood glucose monitoring all required physician notification for out-of-range blood glucose values, which was not followed in this case. Additionally, a review of the resident's medication administration record and feeding orders revealed that the resident missed 14 hours of prescribed tube feeding, which the Assistant Director of Nursing confirmed could contribute to unstable blood sugar and other complications. The failure to initiate the feeding as ordered and the lack of timely physician notification for both the elevated blood sugar and the resident's change in condition resulted in a delay in care and treatment for the resident, who was ultimately transferred to an acute care hospital with diagnoses including diabetic ketoacidosis and hyperkalemia.
Failure to Provide Prescribed Enteral Feeding to Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral feeding did not receive the prescribed diet as ordered by the attending physician. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease, had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube at a rate of 55 ml per hour for 20 hours daily, totaling 1,100 ml and 1,650 kcal per 24 hours. The order specified the feeding should be on at 2 p.m. and off at 10 a.m., or until the dose was completed, with allowances to hold feedings during ADL care, showers, and transfers. Upon review of the Medication Administration Record (MAR) and Medication Admin Audit Report, it was found that the feeding was not initiated as ordered. The MAR indicated the feeding was signed off as 'off' at 10 a.m., but there was no documentation that the feeding had been started prior to this time. The Assistant Director of Nursing (ADON) confirmed that the feeding should have been set up immediately upon admission, as the facility had the necessary supplies and equipment available. The ADON also noted that the nurse did not sign that the feeding was started, resulting in the resident missing 14 hours of prescribed feeding. As a result of this omission, the resident did not receive 770 ml of the prescribed enteral nutrition. The facility's policy and procedure for enteral feeding, last reviewed in April 2025, required that enteral feedings be administered via pump as ordered by the physician. The failure to initiate the prescribed feeding regimen led to the resident not receiving the required nutrition and hydration as ordered.
Failure to Administer Insulin and Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as prescribed, specifically regarding the administration of insulin and blood glucose monitoring. On the morning in question, the resident refused a fasting blood sugar (FSBS) check at 6 a.m., and as a result, did not receive the scheduled dose of Novolin N FlexPen insulin, which was to be administered unless the blood sugar was below 100. The Medication Administration Record (MAR) indicated the FSBS was refused and the insulin was not given, with documentation codes reflecting these actions. The resident had a complex medical history, including type 2 diabetes mellitus, hypertension, gastrotomy, and chronic kidney disease. The resident's records indicated inconsistent capacity to make healthcare decisions, and the Minimum Data Set (MDS) noted that the resident sometimes understood and was sometimes understood. Despite the refusal of the FSBS, previous blood sugar readings at 12:04 a.m. and 11:56 a.m. were 121 and 109, respectively, both above the threshold for holding insulin. Facility policy required medications to be administered according to physician orders and blood glucose testing to be performed as ordered. Later that day, the resident experienced a significant change in condition, including hypotension and an elevated blood sugar level of 379, leading to hospital transfer. The Assistant Director of Nursing (ADON) confirmed that staff should have obtained another blood sugar check at 6 a.m. to ensure accurate assessment and appropriate insulin administration, as the available blood sugar readings did not meet the criteria for withholding the medication.
Failure to Maintain Accurate Clinical Records and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not ensuring that nursing staff properly documented medication administration and related progress notes. Specifically, a Licensed Vocational Nurse (LVN) documented a code '9' on the Medication Administration Record (MAR), which indicates that a progress note should be present to explain why a medication was not given. However, no such progress note was found in the resident's record, resulting in incomplete documentation. Additionally, after the resident was discharged to a general acute care hospital, another LVN did not accurately document in the MAR, further contributing to the inaccuracy of the resident's medical records. The resident involved had multiple complex medical conditions, including type 2 diabetes mellitus, hypertension, a gastrostomy tube, and chronic kidney disease. The resident's care plan included numerous orders such as enteral feeding, medication administration via g-tube, pain monitoring, and regular assessments for side effects and symptoms related to their diagnoses and treatments. The MAR for this resident showed that tasks and medication administrations were signed off as completed, but the required supporting documentation, such as progress notes for exceptions or withheld medications, was missing. Interviews with facility staff, including the Director of Nursing (DON) and the LVNs involved, confirmed that the documentation was incomplete and did not meet professional standards. The DON acknowledged that the absence of accurate documentation could result in an incomplete record and hinder continuity of care, as subsequent staff would not have a clear understanding of the resident's condition or the reasons for any deviations from the care plan. The facility's own policy required complete, legible, and accurate entries in the medical record, which was not followed in this instance.
Incomplete Discharge Documentation and Medical Record Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that the Discharge Planning Review Form was completed and signed by a registered nurse, and by not documenting the resident's refusal to sign discharge documents. The resident, who had diagnoses including anxiety disorder, gastroesophageal reflux disease, and acute respiratory failure with hypoxia, was admitted with intact cognition. Upon discharge, the Discharge Planning Review Form lacked both the licensed nurse's and the resident's signatures, and the resident's refusal to sign was not documented in the medical record. Additionally, licensed nurses did not document the level of care provided, the resident's health status, or the medical records given to the resident on the day of discharge. Progress notes for the resident did not reflect these required details, and the Director of Nursing confirmed that the medical records were incomplete and that documentation of the resident's discharge status was neither timely nor complete. The facility's policy required that progress notes reflect the resident's current status and be documented in a timely manner, which was not followed in this case.
Resident Privacy Not Maintained During Shower
Penalty
Summary
A deficiency occurred when a resident's privacy was not maintained during a shower. Observation revealed that the privacy curtain in the shower room was not fully closed, leaving a gap that exposed the resident while being assisted with bathing. The Licensed Vocational Nurse present acknowledged that the curtain should have been closed to ensure the resident's safety and privacy. The Director of Nursing confirmed that staff are expected to pull the privacy curtain when a resident is undressed in the shower room and that this lapse could cause embarrassment and emotional distress for the resident. The resident involved had a history of dementia, depression, and stroke, and was assessed as having severely impaired cognitive functioning. The resident required moderate assistance with showers and was able to make needs known regarding activities of daily living. Facility policy requires staff to promote and protect resident privacy, including bodily privacy during personal care. The failure to fully close the privacy curtain during the resident's shower did not align with these requirements.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with significant medical needs. The resident had a history of cerebrovascular accident (CVA), epilepsy, depressive disorder, and hemiplegia, and required maximal to moderate assistance with activities of daily living such as toileting, dressing, and hygiene. The resident's care plan specifically directed staff to keep the call light within reach due to these limitations. During an observation, the call light was found placed at the top of the mattress above the resident's pillow, out of the resident's reach. A CNA confirmed that the resident would not be able to access the call light in that position and acknowledged it should have been placed within reach to allow the resident to call for assistance. The DON also confirmed that call lights are required to be within reach, as per facility policy, and that failure to do so could delay necessary care.
Failure to Arrange Transportation for Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident received medically-related social services necessary to achieve the highest possible quality of life by not arranging transportation for a scheduled clinic appointment. The resident, who had a history of cerebral infarction, hemiplegia, heart failure, asthma, and depression, was dependent on staff for daily activities and had moderately impaired cognitive functioning. A physician's order required the resident to attend a follow-up appointment with a pulmonologist, with specific instructions for preparation and transportation. Despite the scheduled appointment and the need for wheelchair-accessible transportation, the Social Services Director did not arrange transportation ahead of time, relying instead on a transportation agency that only accepted same-day requests. On the day of the appointment, no wheelchair-accessible transportation was available, and the facility did not utilize a private transportation agency that could have been scheduled in advance. The Director of Nursing confirmed that there was no facility policy or procedure for arranging transportation, and acknowledged that this failure could potentially delay care and worsen the resident's condition.
Failure to Document Clinic Appointment Arrangements and Outcomes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the arrangements for a scheduled clinic appointment and the outcome of that appointment. The resident, who had a history of cerebral infarction, hemiplegia, heart failure, asthma, and depression, was noted to have moderately impaired cognitive functioning and was dependent on staff for certain activities of daily living. A physician's order indicated a scheduled follow-up appointment with a pulmonologist, including specific instructions for preparation and required documentation to accompany the resident. Upon review, it was found that while the appointment was noted in the resident's records, there was no documentation regarding the transportation arrangements made for the appointment or whether the appointment was completed. The Social Services Director confirmed the lack of documentation for both the transportation and the appointment outcome. The Director of Nursing stated that each discipline is responsible for updating resident records and that such documentation should have been present. Facility policy also requires all disciplines to document relevant resident progress and events in the medical record according to professional standards.
Failure to Reconcile Controlled Medication Kits and Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to reconcile and account for six medication emergency kits (eKITs) containing controlled medications (CMs) in three medication rooms for the month of June 2025. During observations and interviews, it was found that none of the eKITs in Medication Room Stations 1, 2, and 3 had accountability logs for reconciliation of CM inventory at every shift change, as required by facility policy and federal and state regulations. Multiple licensed nurses confirmed that the eKITs were not reconciled at every shift, and the Director of Nursing (DON) acknowledged that the required accountability and reconciliation logs were not maintained for these kits during the specified period. Additionally, the facility did not have an available supply of tramadol, a controlled medication prescribed for moderate to severe pain, which affected a resident who was not administered the medication as ordered. On the morning of June 3, 2025, a licensed vocational nurse (LVN) was observed administering other medications to the resident but did not administer tramadol because it was not available in the medication cart or anywhere in the facility. The LVN instead administered Tylenol, which was only prescribed for lower pain levels, and acknowledged this as a medication error. The resident had reported a pain level of 5, which required tramadol according to the physician's order. Review of the resident's records indicated a history of spondylosis and cervical disc degeneration, with tramadol prescribed for pain levels between 5 and 10. The Medication Administration Record confirmed that tramadol was not administered as ordered. Facility policies reviewed indicated that medications, especially controlled substances, must be administered as prescribed and reconciled at each shift change, but these procedures were not followed, resulting in the deficiencies identified.
Failure to Maintain Safe and Homelike Environment Due to Equipment and Environmental Disrepair
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to maintain a safe, clean, and homelike environment for several residents. For one resident with epilepsy, cognitive communication deficit, and mood disorder, the bed control cord was found to have exposed and frayed wires, partially wrapped with black tape, which was not an appropriate repair. The resident and staff were aware of the issue, but it was not reported promptly to maintenance, and the improper repair was not followed up with a replacement as required by facility policy and equipment manuals. Another resident with hemiplegia, hemiparesis following a stroke, depression, muscle weakness, and a history of falls was found to have a broken baseboard in their room, with two exposed metal nails sticking out. Staff were aware of the broken baseboard but did not report it to maintenance due to being busy. The presence of the broken baseboard and exposed nails was acknowledged by staff as unsafe and not consistent with a homelike environment. Additionally, two residents with significant cognitive and physical impairments, both at risk for falls, were found to have floor mats in disrepair. One resident's floor mat had a linear tear with foam padding exposed, while another's had multiple scratches. Staff and leadership acknowledged that these conditions did not provide a homelike environment and that such issues should have been reported to maintenance for replacement. Facility policies and procedures required prompt reporting and repair of such environmental hazards, but these were not followed in these instances.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple observations, interviews, and record reviews involving four residents. For two residents, staff placed pillows tightly tucked under the fitted sheet on both sides of the bed, which restricted the residents' freedom of movement. These actions were performed for staff convenience and without a physician's order, informed consent, physical restraint assessment, or inclusion in the care plan. Both the Director of Staff Development and the Director of Nursing confirmed that this practice was not permitted, as it prevented residents from moving freely and could be considered a restraint. Another resident was found to be using a low air loss mattress with built-in bilateral upper and lower bolsters for trunk control and postural positioning. However, there was no documentation of a physician's order, informed consent, physical restraint assessment, or care plan for the use of these bolsters. The MDS Coordinator and DON acknowledged that the use of bolsters in this manner could be considered a restraint, as it restricted the resident's movement, and that the required assessments and documentation had not been completed. A fourth resident's bed was placed against the wall to prevent falls, but this intervention was implemented without a physician's order, informed consent, restraint assessment, or care plan. Staff interviews confirmed that these steps were necessary to ensure the safe use of such interventions and to honor the resident's right to informed consent. The facility's own policies required that before any restraint is used, alternative methods must be attempted and documented, and that a comprehensive assessment, physician's order, informed consent, and care plan must be in place, none of which were completed in these cases.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents who were prescribed insulin for diabetes management. For one resident, medical records showed repeated administration of insulin in the same areas, such as the left lower quadrant of the abdomen and the right arm, over multiple days. The resident had diagnoses including type 2 diabetes mellitus, muscle weakness, and mild protein-calorie malnutrition, and was cognitively intact and able to make medical decisions. The order summary for this resident specifically instructed staff to rotate injection sites, but documentation revealed that this was not consistently done. For the second resident, who had type 2 diabetes mellitus with chronic kidney disease and mild protein-calorie malnutrition, similar failures were observed. The resident's records indicated that insulin was administered multiple times in the same area, such as the right or left arm and the abdomen, without proper rotation as required by the physician's orders. This resident had moderately impaired cognition and was also prescribed a sliding scale insulin regimen that included instructions to rotate injection sites. The care plan for this resident included an intervention to administer medications as ordered, but the rotation of injection sites was not consistently documented. Interviews with the Director of Staff Development and the Assistant Director of Nursing confirmed that licensed staff did not always rotate insulin administration sites for these residents. Both staff members acknowledged that site rotation is necessary to prevent complications and that the facility's policy and the prescribing information for Novolog insulin require rotation of injection sites. The facility's policy also outlined the main sites for insulin injection and emphasized the importance of rotating within those areas.
Failure to Maintain a Safe Environment and Prevent Accident Hazards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision in the facility, affecting several residents with varying degrees of cognitive and physical impairment. In several instances, floor mats intended to reduce injury from falls were obstructed by heavy objects such as overbed tables and visitor chairs, as observed in the rooms of residents with documented fall risks and impaired cognition. Staff interviews confirmed that these items should not have been placed on the mats, as this could compromise their effectiveness in preventing injury during a fall. Additionally, a bedside table was found on top of a fall mat in another resident's room, with staff acknowledging this practice was unsafe. Other environmental hazards were also documented, including an uncovered electrical outlet behind a resident's bed and a broken baseboard with exposed nails in another resident's room. Staff admitted to being aware of these hazards but failed to report them, and maintenance personnel confirmed that such conditions were unsafe and not in compliance with facility policy. The presence of these hazards was corroborated by direct observation and staff interviews, and facility policies reviewed by surveyors required immediate reporting and correction of such issues to maintain a safe environment. Additional deficiencies included improper storage of cigarettes and medications. A resident was found with a pack of cigarettes in their possession, contrary to facility policy requiring secure storage of smoking materials. Medications, including topical creams and eye drops, were left at the bedside of two residents without proper physician orders or secure storage, in violation of facility procedures. Staff interviews confirmed that these practices were not in line with established protocols and posed risks as outlined in the facility's own policies and procedures.
Failure to Obtain Required Authorization and Documentation for Bedrail Use
Penalty
Summary
The facility failed to obtain a physician's order, informed consent, a bedrail assessment supporting use, and a care plan for the application of padded bilateral upper bedrails for a resident with hemiplegia, hemiparesis, muscle weakness, and cognitive communication deficit following a cerebral infarction. The resident was admitted with high fall risk and required assistance with mobility and activities of daily living, using both a walker and wheelchair. Despite the resident's capacity to make medical decisions and intact cognition, there was no documentation of a physician's order or informed consent for the use of bedrails. Observation confirmed that the resident's bed had bilateral upper padded bedrails in use, and staff interviews revealed that the bedrails were being used to facilitate mobility in bed and as a fall intervention. However, review of the resident's records showed the absence of a physician's order, informed consent, and a care plan addressing the use of bedrails. The only bedrail assessment present recommended against their use, yet the bedrails remained in place. Interviews with facility staff, including the Director of Staff Development and the Assistant Director of Nursing, confirmed that required procedures were not followed. Facility policy required a detailed healthcare provider order, informed consent, and care planning for bedrail use, but these steps were not completed. The lack of proper assessment, documentation, and consent for the use of bedrails constituted the deficiency identified by surveyors.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. One error involved a resident who did not receive tramadol as prescribed for moderate to severe pain because the medication was not available in the facility at the time of administration. Instead, the resident was given Tylenol, which was only indicated for lower pain levels, despite the resident reporting a pain level of 5. The nurse acknowledged that tramadol should have been available and administered according to the physician's order and facility policy. Another error occurred when a different resident received a multivitamin with minerals, contrary to the physician's order for a multivitamin without minerals. The nurse administering the medication admitted to not following the five rights of medication administration and recognized this as a medication error. The Director of Nursing confirmed that the correct form of the multivitamin was not given and that this could potentially affect the resident's health, especially considering the resident's medical condition, which included a left lower leg wound. Record reviews confirmed that both residents had clear physician orders for their respective medications, and the facility's policies required strict adherence to these orders, including ensuring medication availability and verifying the correct medication before administration. The failures were observed during medication passes and confirmed through interviews with the involved nurse and the Director of Nursing, as well as through review of the residents' medical records and the facility's policies and procedures.
Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by prescriber orders, manufacturer specifications, and accepted professional standards. For two residents with diabetes mellitus, staff repeatedly administered insulin injections in the same anatomical areas over an extended period, as documented in the Location of Insulin Administration Reports. This practice was confirmed through record reviews and interviews with facility leadership, who acknowledged that injection site rotation was not consistently performed. One resident, admitted with type 2 diabetes mellitus, muscle weakness, and mild protein-calorie malnutrition, had intact cognition and was able to make medical decisions. The resident's orders specified the use of a sliding scale for Novolog insulin and explicitly required rotation of injection sites. However, records showed that insulin was frequently administered in the same areas, particularly the right arm, over multiple dates. Facility staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that this failure to rotate sites constituted a medication error and could lead to complications such as bruising, skin injury, and impaired insulin absorption. A second resident, also with type 2 diabetes mellitus and diabetic chronic kidney disease, had similar orders for insulin administration with instructions to rotate injection sites. Despite this, documentation revealed repeated use of the same injection sites, including the right and left arms and the abdomen. Interviews with facility staff again confirmed that the lack of site rotation was a medication error. Facility policies and manufacturer guidelines reviewed during the survey also emphasized the importance of rotating injection sites to prevent adverse effects and ensure proper medication administration.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding safe and sanitary food storage and preparation practices. During an inspection, opened containers of thickened lemon water and almond milk were found to be sticky to the touch, and an opened container of apple juice was not labeled with the date it was opened. Additionally, an opened bottle of brown coloring for gravy was observed with dried dark brown drippings on the side. The Dietary Supervisor confirmed that kitchen staff should have wiped containers clean after each use and labeled all opened items with the date to ensure proper food safety and sanitation. Interviews with the Dietary Supervisor and the Director of Nursing confirmed that the facility's policy requires all food items to be labeled and dated when opened, and that containers should be wiped clean after each use. The policy also states that opened products should be stored in containers with tight-fitting lids and labeled accordingly. The observed failures to follow these procedures had the potential to compromise food safety for residents receiving meals from the kitchen.
Failure to Enforce Food Labeling and Storage Policy for Resident Food Brought by Visitors
Penalty
Summary
The facility failed to enforce its policy regarding the labeling and storage of food items brought in by family members or visitors for residents. During observations and interviews, it was found that multiple food items, including condiments such as ranch dressing, mayonnaise, and red salsa, were stored in the resident-designated refrigerator without being labeled with the resident's name or the date the items were opened and placed in the refrigerator. Staff interviews confirmed that the established procedure requires all such items to be labeled with the resident's name and date, and to be discarded after 48 hours, but this was not consistently followed. The deficiency was identified during kitchen inspections and interviews with dietary, nursing, and administrative staff, all of whom acknowledged the requirement for proper labeling and timely disposal of perishable food items. The facility's policy, last reviewed in January 2024, clearly states that food brought in by visitors must be labeled and stored appropriately to prevent the risk of food-borne illness. However, the observed failure to label and date these items as required placed residents at risk for consuming expired or spoiled food.
Failure to Maintain Infection Control Practices for Resident Items and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in resident care and environmental management. In one instance, a resident with chronic obstructive pulmonary disease, protein-calorie malnutrition, and dementia was found lying in a low bed with a glass of water and a desk phone placed on the floor beside the bed. Additionally, the resident's urinal bottle was not labeled with the resident's name or room number. Staff interviews confirmed that placing personal items on the floor could lead to contamination and that urinals should be labeled to prevent cross-contamination between residents. Further observations revealed that staff repeatedly left mobile linen carts open in the hallway after obtaining supplies, with the carts facing resident rooms. Staff members acknowledged that leaving the carts open exposed clean linens to environmental contaminants, and that clean linens were touched with gloves and PPE after providing resident care, increasing the risk of contamination. Facility policy required that linen carts be covered at all times to prevent contamination, but this was not consistently followed. Additionally, some mobile linen carts were covered with mesh or permeable materials, which staff recognized as inadequate for protecting linens from environmental contaminants. Although there was an effort to replace these covers with non-permeable materials, not all carts had been updated. Facility policies reviewed indicated the importance of proper labeling, storage, and handling of resident care items and linens to prevent infection, but these procedures were not consistently implemented.
Failure to Inform Resident of Medication Names and Indications During Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered seven medications to a resident without informing them of the names and indications of each medication prior to administration. The resident, who had diagnoses including type 2 diabetes mellitus and hypertension, was observed swallowing the medications without being told what they were or their purposes. The LVN later acknowledged not providing this information and stated that the resident spoke Spanish, while the LVN did not, and failed to request a translator as required by facility policy. This omission was confirmed during interviews with both the LVN and the Director of Nursing (DON), who stated that the process of informing residents about their medications is essential for resident rights and decision-making. Facility policy and procedures reviewed indicated that staff are required to explain the type of medication being administered and to accommodate residents' communication needs. The failure to inform the resident of the medication names and indications, and to provide translation services, resulted in the resident not being fully informed about their care and not having the opportunity to make choices regarding their medication regimen.
Call Light Not Kept Within Reach for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident's call light was kept within reach, as required by the resident's care plan and facility policy. During an observation, the call light was found on the floor beside the resident's bed, making it inaccessible. The resident had a history of type 2 diabetes mellitus with a foot ulcer, obesity, and physical deconditioning, which limited mobility and increased dependence on staff for activities of daily living. The resident was cognitively intact and able to communicate needs, and the care plan specifically directed staff to keep the call light within reach and encourage its use for assistance. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Assistant Director of Nursing, confirmed that it was the responsibility of all staff to ensure call lights were accessible to residents at all times. Staff acknowledged that the call light should not have been on the floor and that environmental checks should include verifying the call light's placement. Review of facility policy also indicated that call cords must be placed within the resident's reach. The failure to keep the call light accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Develop and Implement Care Plan for Physical Restraint Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was subject to a physical restraint intervention. Specifically, the resident, who had diagnoses of hemiplegia, hemiparesis following cerebral infarction, and muscle weakness, was admitted with high fall risk and required assistance with mobility and activities of daily living. The resident's bed was placed against the wall as a fall prevention measure, which the Director of Staff Development (DSD) identified as a form of restraint that limited the resident's freedom to exit the bed from both sides. Despite this intervention, there was no corresponding care plan documented in the resident's electronic medical record addressing the use of the bed as a restraint. Further review of the resident's records, including the admission record, history and physical, Minimum Data Set (MDS), and order summary, confirmed the absence of a physician's order or care plan for the restraint intervention. Interviews with facility staff, including the DSD and Assistant Director of Nursing (ADON), revealed that the lack of a care plan led to potential miscommunication among the interdisciplinary team and could result in substandard care. The facility's policy required that a comprehensive care plan be developed within seven days of the baseline assessment, but this was not completed for the restraint intervention used for this resident.
Failure to Provide Resident-Centered Activities and Maintain Accurate Activity Records
Penalty
Summary
The facility failed to provide resident-centered activities for a resident with dementia, major depressive disorder, and generalized muscle weakness. The resident was dependent on staff for transfers and had expressed, through assessment and care planning, a strong preference for participating in religious services, specifically Christian mass, which was considered very important to her. Despite this, the resident was not consistently informed about or brought to religious services, and there was a lack of communication regarding cancellations or alternative activities when the service was not held. Interviews with staff revealed inconsistencies in how residents were notified about activities, with responsibility for informing residents sometimes falling between activity staff and CNAs. On the day in question, the activity assistant did not conduct room visits due to being the only assistant present, and the CNA reported that the resident preferred to stay in bed but did not specifically address the resident's desire to attend religious services. The resident herself stated she had not been told about the religious service and would have attended if invited, emphasizing the importance of these services to her spiritual well-being. Additionally, the facility did not follow its own policy and procedure regarding documentation and tracking of resident participation in activities. The activity director acknowledged that the policy requiring attendance tracking for each activity had not been implemented, resulting in incomplete records of which residents participated in which activities. This lack of documentation and communication contributed to the resident not receiving her preferred activities and the facility not maintaining accurate records as required.
Failure to Document Change of Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to ensure that a change of condition was properly documented and communicated for two residents who were transferred to a general acute care hospital (GACH). For one resident with diagnoses including cognitive communication deficit, type 2 diabetes mellitus, and generalized muscle weakness, there was no eInteract Change of Condition/SBAR form completed by the licensed nurse at the time of transfer for a urinary tract infection. The Minimum Data Set Coordinator confirmed that the required documentation, which should detail the events leading to the transfer and the interventions provided, was missing. The Director of Nursing also stated that the SBAR/Change of Condition form is essential for communicating the resident's status and the care provided during such incidents. Another resident, with a history of acute osteomyelitis, neuropathic bladder, and paraplegia, was transferred to the hospital on two occasions. On one occasion, the progress notes only indicated the transfer for critical laboratory results without documenting vital signs, primary diagnosis, code status, nursing observations, or notifications to the primary physician and resident representative. On another occasion, although an SBAR/Change of Condition was created for worsening edema, it was not updated to reflect the actual transfer, and the provider notified was not documented. The Director of Staff Development and Assistant Director of Nursing both acknowledged that the required documentation was incomplete or missing, which is necessary to ensure safe transfer and accurate communication of the resident's condition and care. The facility's policy requires that any change in a resident's condition be documented in detail, including the incident, assessments, notifications, and updates to the care plan. However, in both cases, the facility did not follow its own procedures, resulting in incomplete records of the residents' changes in condition and the care provided prior to hospital transfer. This lack of documentation could lead to delays in care and inadequate communication among healthcare providers and resident representatives, as noted in the findings.
Failure to Maintain Catheter Tubing Free of Kinks or Loops
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have a loop in the catheter tubing, which prevented urine from flowing freely into the drainage bag. During the observation, a CNA confirmed that the tubing contained urine and white sediment, and acknowledged that staff are responsible for ensuring the catheter bag is below the bladder, covered for privacy, and that the tubing is free from kinks or loops. The facility's policy also requires that catheter tubing be kept free from kinking and that the collection bag remain below the bladder level. The resident involved had a history of obstructive uropathy, pneumonia, and type 2 diabetes mellitus, and required varying levels of assistance with activities of daily living due to impaired cognition and lower extremity impairment. Physician orders specified monitoring the catheter and drainage bag for issues such as sediment, foul odor, hematuria, and bladder distention every shift. Both the CNA and the DON confirmed that the presence of a loop or kink in the catheter tubing is contrary to standard practice and facility policy, as it can impede urine flow.
Failure to Properly Rinse Medication Syringe for Enteral Feeding
Penalty
Summary
A deficiency occurred when a licensed nurse failed to properly rinse a medication syringe after administering medication via a gastrostomy tube to a resident. The resident, who was non-verbal, had severely impaired cognition, and required total assistance with all activities of daily living, was observed to have a medication syringe stored in a plastic bag with yellow liquid at the bottom and a yellowish white dried powdery substance stuck to the side. The facility's care plan and physician's orders required that syringes be rinsed thoroughly after each use to prevent complications, and the manufacturer's guidelines also specified thorough rinsing after each use. During an interview, the Assistant Director of Nursing confirmed that the syringe should have been rinsed well before being placed back in the storage bag, as failure to do so could place the resident at risk for gastrointestinal problems. The observation and record review confirmed that the nurse did not follow established protocols for syringe care, resulting in the potential for complications associated with enteral feeding.
Failure to Label IV Dressing with Date of Last Change
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including obstructive uropathy, pneumonia, and type 2 diabetes, was observed with a midline catheter dressing that did not indicate the date of the last dressing change. The resident required substantial assistance with activities of daily living and had physician orders for regular flushing of the IV lumen and dressing changes every 48 hours. Facility policy required midline dressings to be changed every seven days or as needed if soiled, loose, or leaking, and to be labeled with the date and time of the last change. During observations, the resident was found with a loose and soiled transparent dressing on the upper arm, which the resident reported became loose after a shower. Interviews with the ADON and DON confirmed that the dressing was not labeled with the date of the last change, contrary to facility policy and professional standards. Both nursing leaders acknowledged that the absence of labeling could prevent staff from knowing when the dressing was last changed, potentially increasing the risk of infection at the insertion site.
Failure to Ensure Timely Physician Notification and Emergency Preparedness for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis. The resident had medical orders for hemodialysis three times weekly, as well as instructions to keep the dialysis site dressing dry and intact, and to monitor for signs of infection, bleeding, drainage, and pain. Despite these orders, the facility did not follow up with the resident's attending physician when the resident missed a scheduled dialysis appointment. Review of nursing progress notes and interviews with the Director of Nursing (DON) confirmed that there was no physician follow-up documented after the missed dialysis session. Additionally, the facility failed to ensure that a dialysis emergency kit was readily available at the resident's bedside. During an observation and interview, it was noted that the dialysis kit, which is intended to provide immediate care in case of emergencies such as bleeding, was missing from the resident's room. Both the resident and the LVN confirmed that the kit had not been present for at least two weeks, and a search of the room and closet did not locate it. The DON confirmed that each dialysis resident should have a kit at the bedside and described its contents and purpose. Facility policies and procedures required that residents who require dialysis receive services consistent with professional standards and that nursing staff keep the physician informed of any changes in condition. The policies also specified that staff should be trained in emergency care for dialysis residents, including management of hemorrhage. The failure to follow up with the physician after a missed dialysis session and the absence of a dialysis kit at the bedside constituted deficiencies in the provision of safe and appropriate dialysis care.
Failure to Properly Label and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and manufacturer requirements. In one instance, an opened multi-dose vial of epoetin alfa for a resident was found in the medication room refrigerator without a date indicating when it was first used or when it would expire. The manufacturer's instructions specified that multi-dose vials should be discarded no later than 21 days after first use, and facility policy required the date of opening and expiration to be recorded on the vial. Both the RN and the DON confirmed that the vial was not labeled as required and should have been removed from use, as its effectiveness could not be guaranteed. Additionally, the facility failed to properly label intravenous (IV) ertapenem administered to another resident. The IV bag containing ertapenem, which was prepared from the emergency medication kit, was not labeled with the resident's name or the rate of administration. Facility policy and standard nursing practice require that all medications, especially those from emergency kits, be labeled with the resident's name, medication name, dose, route, date, and rate of administration to ensure safe and accurate medication delivery. The nurse responsible for administering the ertapenem acknowledged that the labeling was incomplete due to being in a hurry, and the DON confirmed that this was not in accordance with facility policy. Both deficiencies were identified through direct observation, interviews with nursing staff and the DON, and review of facility policies and manufacturer instructions. The lack of proper labeling and storage had the potential to result in the use of expired or ineffective medication and could have led to medication administration errors, as the required information to verify the correct resident and administration details was missing.
Failure to Timely Address and Document Dental Complaint
Penalty
Summary
The facility failed to promptly provide dental services for a resident who was admitted with diagnoses including dysphagia, GERD, and anxiety disorder. The resident had moderate cognitive impairment but was able to make decisions and communicate needs. A family member verbally reported the resident was experiencing a toothache to the Social Services Director (SSD), but the SSD did not document the chief complaint or ensure a timely and specific referral to the dentist. When the resident was eventually seen by the dentist, the dental record did not indicate the reason for the referral or the resident's chief complaint. The dentist documented no pain, no swelling, and no visible pathology, but there was no evidence that the toothache complaint was addressed. The SSD acknowledged that the dental referral log and dental records lacked documentation of the chief complaint, and she was unsure if the resident was evaluated for the reported toothache. Additionally, the SSD did not follow up with the family member to confirm whether the dental issue had been resolved. Interviews with other staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that the process for referring and following up on dental complaints was not followed as required by facility policy. The lack of documentation and follow-up had the potential to result in unresolved pain and discomfort for the resident.
Failure to Designate Qualified Hospice Coordinator for Resident Care
Penalty
Summary
The facility failed to designate a qualified hospice coordinator responsible for coordinating care between hospice representatives and facility staff for a resident receiving hospice services. The Medical Records Director (MRD) was assigned as the hospice coordinator, but interviews and record reviews revealed that the MRD's role was limited to ensuring hospice medical records were complete and updated, and he was not involved in coordinating care or participating in the interdisciplinary team (IDT). The MRD's background was in medical billing and quality assurance in home health, and the job description for the Health Record Coordinator did not include hospice coordination responsibilities. A review of the resident's records showed that the resident was admitted with diagnoses including malignant neoplasm of the cervix, palliative care, and cerebral infarction, and was on hospice care with a terminal prognosis. The resident was mostly dependent on mobility and activities of daily living, and had a condition with a life expectancy of less than six months. The care plan indicated the need for cooperative work with the hospice team to meet the resident's needs, but there were missing signatures and incomplete documentation in the hospice binder, which was not updated and could not be located at the time of review. Interviews with facility staff, including the Case Manager and Assistant Director of Nursing (ADON), confirmed that there was no specific individual assigned as hospice coordinator, and that the MRD, who was designated as such, did not have the clinical background or involvement in care coordination required for the role. The facility's policy required collaboration between hospice and facility staff, but the lack of a qualified hospice coordinator led to deficiencies in the coordination and documentation of hospice care for the resident.
Failure to Maintain Safe Bed Equipment for Resident
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition by not ensuring that a resident's bed frame control was in good repair. Specifically, the bed control cord for a resident with epilepsy, cognitive communication deficit, and mood disorder was found to have frayed and exposed wires. The resident, who required substantial assistance with daily activities and was dependent on staff for mobility, reported the issue, noting that black tape had previously been applied to the cord but that exposed wires remained visible and the repair was inadequate. Observations confirmed that the bed control cord had exposed and frayed wires, sometimes with and sometimes without black tape. Staff interviews revealed that a CNA noticed the exposed wires but did not report the issue immediately due to being busy, acknowledging that it should have been reported to maintenance right away. The Maintenance Assistant admitted to previously repairing the cord with tape but was unaware of further issues, while the Maintenance Director stated that taping over exposed wires was not an appropriate repair and that the bed or control should have been replaced if a proper repair could not be made. The facility's policies and procedures, as well as the bed frame manual, require that equipment be maintained in a safe and operable manner, with repairs performed only by authorized personnel and damaged electrical components not to be used. The Director of Nursing confirmed that the facility's policy was not followed in this instance, as equipment issues are to be reported immediately to ensure a safe and homelike environment for residents.
Inaccurate Activity Documentation Due to Shared Staff Logins
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two residents reviewed under the Activities care area. Specifically, activity documentation did not accurately reflect which activity staff member provided services to the residents. For both residents, records indicated that an activity assistant had signed for days when she was not present, and other staff members used her login credentials to document activities, rather than having their own access. One resident, admitted with dementia, major depressive disorder, and generalized muscle weakness, was dependent on staff for transfers and had a care plan emphasizing participation in religious services. Documentation for this resident showed that the activity assistant was recorded as providing services on days she was not working. The assistant confirmed she did not sign on those dates, indicating inaccurate recordkeeping. Another resident, with diagnoses including dementia, schizoaffective disorder, and COPD, also had activity records showing the same assistant's signature on days she was not present. Interviews revealed that other activity assistants did not have their own electronic charting access and used the assistant's login to document care. The DON confirmed that each staff member should have individual access to ensure accurate and validated documentation, and that signing for others is not accurate and poses confidentiality risks. Facility policies required that only authorized staff document in medical records and that staff may not sign for another person.
Cluttered Patio Compromises Resident's Homelike Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident when their patio was cluttered with belongings from multiple residents, including four clear trash bags with facility curtains, three facility mattresses, and a wheelchair, all covered with a blue tarp. This situation was observed during an interview with the resident, who expressed concerns about the clutter and potential presence of rodents under the tarp, which discouraged them from using the patio. The resident had been admitted with diagnoses including contracture of muscles, rheumatoid arthritis, and major depressive disorder, and required substantial assistance with daily activities. The Environmental Director confirmed that the items had been on the patio for a week and included residents' belongings and facility items. The Director of Nursing acknowledged the resident's complaint and admitted that the patio was cluttered, limiting space for residents and creating an unattractive environment. The facility's policy emphasized providing a safe, clean, and homelike environment, which was not upheld in this instance, as the patio's condition was not addressed despite the resident's complaint.
Inaccurate Documentation of Resident's Change of Condition
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident who was transferred to a General Acute Care Hospital (GACH) due to a complaint of a possible infection on the dialysis access port. The incident occurred when the resident complained at 11:50 p.m. on 9/4/2024, but the Change of Condition (COC) Evaluation form documented the complaint as occurring on 9/5/2024. This discrepancy resulted in inaccurate information in the resident's clinical record, as the attending physician was notified on 9/5/2024 at 1 a.m., which was recorded as 22 hours and 50 minutes before the documented complaint time. The Director of Nursing (DON) acknowledged that the documentation error was due to a typographical mistake by LVN 1, who admitted to the error and emphasized the importance of double-checking documentation before closing it. The facility's policy on Alert Charting Documentation, last reviewed on 5/23/2024, was intended to ensure timely and accurate documentation of residents experiencing a change in condition. However, the failure to adhere to this policy led to an inaccurate timeframe of events in the resident's clinical records.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 52, who was admitted with end-stage renal disease, cerebrovascular disease, aphasia, and muscle weakness, was observed with a call light placed on the side of his contracted arm, making it inaccessible. Despite the care plan indicating the need for the call light to be within reach, the call light was not positioned correctly, as confirmed by a CNA and the DON. Resident 8, who has severely impaired vision and cognition, was found with the call light on the floor, unclipped from the bed sheets. The CNA confirmed that the resident's habit of playing with the call light often resulted in it being out of reach, which could prevent the resident from calling for help. Similarly, Resident 179, who preferred to lay with her head at the foot of the bed, had her call light positioned at the head of the bed, making it inaccessible. The CNA acknowledged the importance of having the call light within reach to ensure the resident could call for assistance. Resident 14, who has generalized muscle weakness and vascular dementia, was observed with the call light hanging on the bed rail and touching the floor, out of reach. The CNA and DON both confirmed that the call light should have been within reach to allow the resident to request assistance. The facility's policy, which mandates that call cords be placed within the resident's reach, was not followed in these instances, leading to the deficiency.
Failure to Ensure Proper Use of Bed Rails and Restraints
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 118 and 378, were free from the use of physical restraints without proper assessment and documentation. Resident 118 was admitted with conditions including surgical amputation, muscle weakness, and unsteadiness of the feet. Despite having the capacity to understand and make decisions, the resident's bed was placed against the wall with both upper bed rails up, without a physician's order or informed consent. The facility's records showed contradictory recommendations regarding the use of side rails, and there was no documentation of a safety assessment or education provided to the resident or their representative about the risks and benefits of bed rail use. Similarly, Resident 378, who was admitted with hepatic encephalopathy, seizures, and muscle weakness, also had their bed placed against the wall with both upper bed rails up. Like Resident 118, there was no physician's order, informed consent, or documentation of a safety assessment for the use of bed rails and bed placement. The facility's policy required a physician order and informed consent for the use of restraints, which was not adhered to in these cases. The facility's failure to conduct proper assessments and obtain necessary consents for the use of bed rails and bed placement against the wall posed potential risks to the residents, including restriction of movement, physical harm, and psychosocial harm. The facility's policy emphasized the need for restraints to be used only when necessary and with proper documentation, which was not followed in these instances.
Deficiencies in Care Planning and Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For two residents, the facility did not create care plans addressing the use of physical restraints, such as bed rails and bed placement against the wall, despite their high risk for falls. Observations revealed that both residents had their upper bed rails up and beds placed against the wall, yet there were no care plans to guide staff on these interventions. Interviews with nursing staff and the Director of Nursing confirmed the absence of care plans, which are essential for standardizing care and ensuring resident safety. Another resident, who was receiving vancomycin hydrochloride for a serious bacterial infection, did not have a care plan developed for the use of this medication. The resident had a stage four pressure ulcer and required intravenous antibiotics, but the lack of a care plan meant that staff were not adequately informed about the resident's treatment needs. The Director of Nursing acknowledged that a care plan should have been created when the antibiotic order was received to prevent delays in care. Additionally, the facility failed to monitor and document the use of Risperdal for a resident with delusions. The resident's medication administration record lacked documentation for monitoring delusions, side effects of Risperdal, and alternative therapies. Interviews with nursing staff and the Director of Nursing revealed that there was no care plan for managing the resident's delusions or monitoring the effectiveness and side effects of Risperdal. This oversight could lead to unnecessary medication use and potential harm to the resident.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating insulin injection sites for three residents, leading to potential adverse effects. Resident 7, who was admitted with type 2 diabetes mellitus and other related conditions, received insulin injections repeatedly in the same areas, such as the left arm and abdomen, without proper site rotation. This practice was confirmed during a review of the resident's records and interviews with the nursing staff, who acknowledged the failure to rotate injection sites as required. Similarly, Resident 118, diagnosed with type 2 diabetes mellitus and obesity, also experienced non-rotated insulin injections. The records showed repeated administration in the same areas, such as the left arm and lower quadrants of the abdomen. Interviews with the nursing staff confirmed the oversight, highlighting the importance of site rotation to prevent complications like lipodystrophy and tissue hardening. Resident 109, with a history of type 2 diabetes mellitus and other health issues, was also subjected to non-rotated insulin injections. The records indicated repeated use of the right arm and specific abdominal quadrants for insulin administration. The nursing staff acknowledged the deficiency during interviews, emphasizing the necessity of rotating injection sites to avoid adverse effects. The facility's prescribing information for insulin also underscored the importance of site rotation to mitigate risks associated with repeated injections in the same area.
Failure to Prevent Accidents and Hazards for Residents
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. Resident 326, who used tobacco, was found to have cigarettes stored at his bedside, contrary to the facility's smoking policy. The interdisciplinary team (IDT) did not assess whether Resident 326 was an independent or at-risk smoker, which is a requirement for ensuring safe smoking practices. This oversight had the potential to result in a facility fire or resident injuries from burns. Resident 6 was left unattended with her bed in a high position, despite being at high risk for falls due to her medical conditions, including vascular dementia and limited mobility. The facility's policy required beds to be kept in a low position to minimize fall risks, but this was not adhered to, increasing the potential for Resident 6 to sustain injuries from falls. Resident 8, who had severe cognitive and visual impairments, was not accurately assessed for elopement risk. Despite having a history of attempted elopement and wearing a wander guard, the facility's elopement evaluation did not reflect these risks, failing to guide staff in implementing appropriate interventions. This inaccuracy in assessment could lead to inadequate supervision and increased risk of elopement for Resident 8.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three residents. For Resident 62, the water flush bag was labeled with an incorrect infusion rate of 60 ml/hr instead of the physician-ordered 45 ml/hr. This discrepancy was observed during a room visit, and the Infection Preventionist confirmed the error, emphasizing the importance of adhering to physician orders to ensure proper hydration and nutrition. Resident 379's irrigation syringe was not labeled with the resident's identifier or the date it was last changed. This oversight was noted during an observation, and the Business Office Staff confirmed the lack of labeling. The Director of Nursing highlighted the importance of labeling for infection control and ensuring the syringe is changed every 24 hours, as per facility policy. For Resident 17, the tube feeding formula was not labeled with the rate and time it was hung. During an observation, the Nepro 1.8 bottle was found without this critical information. An LVN confirmed that proper labeling is necessary to ensure the formula is used within its safe period and that the resident receives the correct amount of feeding. The Director of Nursing reiterated the importance of labeling to prevent nutritional imbalances.
Failure to Document and Retain Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received care consistent with professional standards and the comprehensive person-centered care plan. Specifically, the facility did not perform and document post-dialysis assessments for Resident 52, who was admitted with end-stage renal disease and other medical conditions. The resident's care plan required monitoring for signs of complications from dialysis, but there were multiple instances where post-dialysis assessments were not documented. Additionally, the facility did not maintain written documentation from the hemodialysis center. The Minimum Data Set Coordinator (MDSC) and Licensed Vocational Nurse (LVN) involved in the resident's care confirmed that the written communication from the dialysis center, which included vital signs and other important information, was not retained in the resident's medical record. Instead, the documentation was shredded, contrary to the facility's policy that required such records to be scanned and saved. The Director of Nursing (DON) acknowledged that the facility's process was not followed, as the written assessments from the dialysis center were not maintained in the resident's chart. The facility's policy emphasized the importance of maintaining complete and accurate medical records, and the contract with the dialysis center required timely documentation. The failure to document and retain these assessments placed the resident at risk for undetected complications from dialysis.
Improper Use of Bed Rails for Two Residents
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed rails for two residents, leading to deficiencies in their care. Resident 118, admitted with conditions including surgical amputation and muscle weakness, was found with both upper bed rails up without a physician's order or informed consent. The bed rail assessment for this resident contained contradictory recommendations, and there was no documentation of education on the risks and benefits of bed rail use. This oversight was confirmed during an observation and interview with the nursing staff, who acknowledged the lack of necessary assessments and consents. Similarly, Resident 378, admitted with diagnoses such as hepatic encephalopathy and seizures, also had both upper bed rails up without a physician's order, bed rail assessment, or informed consent. The facility's policy required an individual assessment and informed consent before the use of bed rails, which was not adhered to in this case. The Director of Nursing confirmed the absence of these critical steps during an interview, highlighting a systemic issue in the facility's adherence to its own policies. The facility's policy and procedure on side rails, last reviewed in May 2024, emphasized the need for an interdisciplinary team to assess the risk of entrapment and obtain informed consent when bed rails are used. The policy also required maintaining a side rail evaluation in the resident's medical record and developing a care plan reflecting that assessment. However, these procedures were not followed for Residents 118 and 378, resulting in potential risks of physical harm, restriction of movement, and other negative outcomes associated with improper bed rail use.
Medication Accountability and Documentation Failures
Penalty
Summary
The facility failed to account for doses of controlled substances for three residents across two medication carts. Specifically, one dose of hydrocodone with acetaminophen was missing for Resident 63, and one dose of pregabalin was missing for Resident 226 in Medication Cart Station 1 Cart 1. Additionally, one dose of oxycodone with acetaminophen was missing for Resident 12 in Medication Cart Station 3 Cart 3A. Licensed Vocational Nurses (LVNs) 1 and 2 admitted to administering these medications but failed to document the administration on the Individual Narcotic Record accountability log, which is against the facility's policy. The facility also failed to document the disposition of non-controlled medications in three medication rooms. The Drug Disposition Record logs were not consistently documented, which could potentially lead to medication diversion. The Director of Nursing (DON) and LVNs acknowledged that the logs were not being maintained as required, and the lack of documentation was attributed to a possible lack of education among the nursing staff. The residents involved had significant medical histories. Resident 12 and Resident 63 both had pressure ulcers and were prescribed pain medications, while Resident 226 had a diagnosis of muscle weakness and was prescribed pregabalin for neuropathy. The failure to document medication administration and disposition could have led to medication errors, impacting the residents' health and well-being.
Failure to Monitor and Justify Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of Risperdal, an antipsychotic drug. The resident, who was admitted with a diagnosis including dementia, was prescribed Risperdal for delusions without a specific, measurable target behavior being identified. The Minimum Data Set (MDS) indicated that the resident had no mood or behavioral symptoms, including delusions, and no psychiatric or mood disorder diagnosis, yet the resident received antipsychotics on a routine basis. The Medication Administration Record (MAR) for the resident from March to May 2024 showed that there was no documentation for monitoring the specific occurrences of delusions, adverse effects of Risperdal, or the use of alternative therapies. The facility's pharmacy consultant noted that the resident lacked an allowable diagnosis to support the use of Risperdal, and there was no follow-up from the physician regarding this note. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the absence of monitoring for specific occurrences of delusions, side effects of Risperdal, and non-pharmacological interventions. The facility's policy and procedures for Behavior/Psychoactive Drug Management require specific behavior manifestations for psychoactive medication orders and monitoring for side effects. However, the facility failed to include specific target behaviors for the use of Risperdal, monitor the specific occurrences of delusions, and implement non-pharmacological interventions. This lack of adherence to policy and procedure placed the resident at risk for significant adverse effects from the use of unnecessary antipsychotic drugs.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. The report highlights that the facility did not adhere to the prescribed practice of rotating subcutaneous insulin injection sites for three residents, which is crucial to prevent complications such as lipodystrophy and cutaneous amyloidosis. This deficiency was identified through interviews and record reviews, where it was noted that insulin was repeatedly administered in the same areas, contrary to the physician's orders and professional standards. Resident 7, who was admitted with type 2 diabetes mellitus and other related conditions, had multiple instances where insulin was administered without proper site rotation. The records showed repeated injections in the same areas over several months, despite clear orders to rotate sites. Similarly, Resident 118, also diagnosed with type 2 diabetes mellitus, experienced the same issue, with insulin injections not being rotated as required. The facility's failure to follow the prescribed rotation protocol was confirmed during interviews with nursing staff, who acknowledged the oversight and its classification as a medication error. Resident 109, with a history of type 2 diabetes mellitus and other health issues, was also affected by this deficiency. The records indicated that insulin was administered in the same areas repeatedly, without adherence to the rotation guidelines. Interviews with the Director of Nursing and Registered Nurse 2 confirmed that the lack of site rotation constituted a medication error, as it did not comply with the physician's orders, professional nursing practice, and manufacturer guidelines. The facility's policy on medication errors was reviewed, and it was noted that the failure to rotate injection sites was not in alignment with the established procedures.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to adhere to its policy of recording medication refrigerator temperatures twice daily, as observed in two of the three inspected medication rooms. From June 1, 2024, to June 26, 2024, the temperature logs in Medication Room Station 3 and Medication Room Station 1 showed documentation of temperature checks only once a day during the 11 PM to 7 AM shift. Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 both confirmed that the refrigerator temperatures were monitored and documented only once daily, which was contrary to the facility's policy and the CDC guidelines requiring twice-daily checks. The Director of Nursing (DON) acknowledged that the facility's policy required twice-daily temperature monitoring, especially since vaccines were stored in the refrigerators. The DON expressed concern that without proper monitoring, the efficacy and potency of the vaccines could be compromised, potentially leading to the use of ineffective or expired medications. The facility's Policy & Procedures, dated May 2022, emphasized the importance of storing medications and biologicals safely and securely, following manufacturer's recommendations or those of the supplier, which includes maintaining appropriate temperature ranges.
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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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