Maclay Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 12831 Maclay Street, Sylmar, California 91342
- CMS Provider Number
- 555583
- Inspections on file
- 96
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 50 (1 serious)
Citation history
Health deficiencies cited at Maclay Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse investigation policy by not obtaining interviews or written statements from all staff assigned to residents involved in two separate resident-to-resident physical contact incidents. In one incident, a cognitively impaired resident with dementia and another resident with ESRD, COPD, and HTN had physical contact witnessed by an RN, but assigned LVNs and CNAs were not interviewed or documented as witnesses. In a second incident in the activity room, two cognitively intact residents using wheelchairs made contact, followed by physical contact between them; assessments showed no injuries, but assigned CNAs and an LVN were not interviewed, and no staff statements were documented for one of the residents. The facility’s abuse policy requires interviewing all relevant staff and obtaining signed, dated written witness statements, which the DON and administrator acknowledged was not done, resulting in incomplete investigations.
A resident with dementia and multiple chronic conditions was transferred to a hospital after an incident and remained there for several days, but two LVNs continued to document administration of ordered medications on the MAR during the period the resident was not in the facility. Progress notes clearly showed the dates of transfer and readmission, yet the MAR reflected doses of atorvastatin, levothyroxine, pantoprazole, and other medications as given in the interim. In interviews, the ADON and DON confirmed the resident’s absence during the documented administrations, acknowledged that the record was inaccurate, and noted that medications should have been documented as not given, contrary to the facility’s charting and documentation policy.
A resident with ESRD, COPD, and HTN, who was cognitively intact and had decision-making capacity, was ordered Lokelma for hyperkalemia but refused a scheduled dose. The MAR documented the refusal, yet no person-centered care plan was developed to address the medication refusal. During interviews, the ADON and DON acknowledged that the nurse should have notified the physician and that a care plan should have been created to address the refusal and ongoing management of hyperkalemia, contrary to the facility’s comprehensive care plan policy.
A resident with moderate cognitive impairment and multiple health conditions was pushed by a roommate with a history of behavioral issues, resulting in a fall. The incident was witnessed and reported by staff and another resident, and both parties involved admitted to their actions. The facility's abuse prevention policy was not followed, leading to a failure to protect the resident from physical abuse.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a breakdown of required communication.
A resident with a history of dysphagia and neurological impairment did not receive a physician-ordered speech therapy and swallow evaluation because the facility lacked a speech-language pathologist. Despite ongoing documentation of swallowing difficulties and pocketing food, there was no evidence that the MD was notified about the inability to provide the ordered service or the resident's continued symptoms, leading to a decline in condition and transfer to acute care.
A resident with multiple medical conditions, including dysphagia and dementia, experienced weight loss and was not provided with a recommended nutritional supplement (magic cup) as advised by the RD. The DON confirmed the recommendation was not implemented, despite facility policy requiring intervention for undesirable weight changes.
A resident with a history of stroke, dysphagia, and dementia did not receive a physician-ordered speech therapy and swallow evaluation due to the absence of an ST in the facility. Despite ongoing documentation of swallowing difficulties and pocketing food, the evaluation was not completed, and there was no evidence that the MD was notified of the inability to provide the service. The resident's condition declined, resulting in transfer to an acute care hospital.
A resident with complex medical needs did not have accurate or complete documentation of a physician-ordered seven-day calorie count. The MAR lacked staff sign-off, and there were discrepancies between the Calorie Count and Meal Intake records, with conflicting or missing entries. The DON confirmed the records were inconsistent and not in accordance with facility policy.
Staff were observed wearing gloves in the hallway after providing care, including while transporting soiled linens and assisting residents, contrary to facility infection control policies. Interviews confirmed that gloves should be removed before exiting resident rooms and soiled linens should be bagged prior to transport, but these procedures were not followed, increasing the risk of infection transmission.
Two residents with significant medical and psychiatric histories were left unsupervised in a smoking patio, where a verbal altercation escalated to physical abuse involving a knife, resulting in one resident sustaining multiple injuries requiring hospital treatment. Staff and video evidence confirmed the absence of required supervision, and facility policy mandated staff presence during such activities.
Two residents with behavioral and cognitive impairments were left unsupervised in the smoking patio, leading to a verbal and physical altercation in which one resident used a knife to injure the other. Staff failed to follow care plans and facility policies requiring supervision during smoking, and the incident was not observed or interrupted by staff, resulting in injury and hospital transfer.
Sensitive medical documents and electronic records for several residents were left unattended and accessible to unauthorized individuals, including visitors and staff not involved in their care. A narcotic medication sheet was left visible at a nurse station, and clinical records were left open on a computer, violating facility policy and residents' rights to privacy and confidentiality.
The facility did not ensure that required physician or NP visits were conducted and documented in a timely manner for three residents with chronic medical conditions, as evidenced by missing or incomplete progress notes and gaps in medical records, contrary to facility policy and federal regulations.
Three residents experienced deficiencies in medical record documentation, including unsigned and undated physician telephone orders, lack of monthly physician review of order summaries, and the presence of blank forms signed by a nurse practitioner. These issues were confirmed through record reviews and staff interviews, revealing that required documentation and authentication were not completed as per facility policy.
Two residents with psychiatric and physical conditions engaged in a verbal and physical altercation in the smoking patio, resulting in one resident injuring the other with a knife. The facility did not thoroughly investigate the incident, failed to locate the weapon, and lacked staff supervision in the area at the time, as confirmed by video surveillance and administrator statements.
A resident with multiple mental health diagnoses, including anxiety disorder, schizophrenia, and psychosis, was admitted without an accurate PASARR Level I Screening reflecting their psychiatric conditions. Despite documentation of these diagnoses in admission records, MDS assessments, and psychiatric evaluations, the initial PASARR did not identify the need for a Level II Screening, resulting in a failure to coordinate assessments as required.
A facility failed to follow its medication storage policy by leaving a resident's discontinued medication in an unlocked drawer at the nurse station, rather than in a locked medication cart or room. The resident, who had intact cognitive skills and was admitted with conditions including diabetes and hypertension, did not have a physician order for the dietary supplement found. Both an LVN and the DON confirmed the oversight and the potential risk of unauthorized access.
A resident with COPD and other conditions did not receive the correct dosage of Atrovent as per physician orders due to a failure in verifying medication orders. The facility's policy requires clarification of unclear orders, which was not followed, leading to a potential medication error.
A facility failed to maintain a system for managing controlled substances, resulting in the unaccounted loss of a resident's Lorazepam medication. Despite having policies for handling and documenting controlled substances, the facility's procedures were not followed, as revealed by interviews with staff and an internal investigation. The resident, with a history of anxiety and other medical conditions, had a physician's order for the medication, but the exact number of missing tablets could not be determined.
A resident with intact cognitive skills and a preference to self-administer diabetes medication was not allowed to do so, as the facility failed to initiate the necessary assessment and care plan. Despite the resident's preference being communicated to nursing staff, the medication was administered by clinicians, contrary to the facility's policy that allows self-administration if deemed appropriate by the interdisciplinary team.
A facility failed to assess a resident's ability to self-administer Trulicity, a diabetes medication, as required by policy. Despite the resident's preference to self-administer, no assessment or physician's order was obtained, and the resident was allowed to self-administer the medication multiple times. The Director of Nursing confirmed the lack of assessment and documentation, which placed the resident at risk for medication errors.
A facility failed to create a care plan for a resident with type 2 diabetes, depression, and hypertension, who was receiving Trulicity. Despite intact cognitive skills, there was no order for self-administration, and no care plan was developed. Staff interviews revealed non-compliance with the facility's policy on self-administration, which required assessment, education, and a care plan. This oversight risked inconsistent care and potential medication complications.
A resident with type 2 diabetes, depression, and hypertension was found to be without a physician order to self-administer Trulicity, despite having intact cognitive skills. The facility's policy requires a physician order and an interdisciplinary team assessment for self-administration, which was not documented, potentially leading to confusion in care delivery.
A resident with type 2 diabetes was allowed to self-administer Trulicity without a physician's order, despite facility policy requiring such an order and an interdisciplinary team assessment. The resident self-administered the medication multiple times, as confirmed by a nurse and the DON, who acknowledged the failure to follow proper procedures.
A resident with moderate cognitive impairment was physically abused by another resident with severe cognitive impairment, resulting in a scratch on the arm. The incident was witnessed by another resident and confirmed as abuse by facility staff, highlighting a failure to protect residents from abuse as per facility policy.
A resident with severe cognitive impairment and multiple health issues was allegedly abused by a CNA, who reportedly hit the resident with a dirty brief. The incident was not reported to the necessary authorities within the required two-hour timeframe, as per facility policy. The delay in reporting was confirmed by interviews with facility staff, highlighting a deficiency in adhering to abuse reporting protocols.
A facility failed to maintain complete and accurate medical records for a resident with a hip fracture, dysphagia, and hypertension. Discrepancies were found between the resident's cognitive assessment and their documented decision-making capacity. An incident involving alleged rough handling by a CNA was not accurately recorded, violating the facility's policy for complete and accurate documentation.
A resident with severely impaired cognition was physically abused by another resident with a history of aggressive behavior in a shared room. The aggressor placed an arm around the victim's neck and punched the victim multiple times, resulting in swelling and bleeding. Staff confirmed the incident as physical abuse, and the facility's failure to prevent it was acknowledged.
A facility failed to provide a safe and homelike environment for four residents due to unresolved plumbing issues in their restrooms. Residents were forced to use alternative restrooms without proper communication or preparation, compromising their privacy and safety. The Director of Nursing was unaware of the situation, and the facility's policy on maintaining a homelike environment was not followed.
A resident with a known onion allergy was served baked beans containing onions, despite their allergy being documented in their medical records and meal tray ticket. The dietary staff failed to adhere to the facility's policies on food allergies, resulting in the resident being exposed to the allergen. The resident did not consume the beans, aware of their allergy, and expressed concern about the potential presence of onions.
A facility failed to treat residents with dignity and respect, as LVN did not knock before entering a resident's room and left medications for self-administration against policy. The resident felt disrespected, and other residents reported unprofessional behavior. Additionally, a CNA undressed a resident in view of the hallway, compromising privacy. These actions violated facility policies on resident rights and quality of life.
The facility failed to conduct restraint assessments and obtain necessary consents for three residents. A sensor pad alarm was used on a resident without assessment, and beds were placed against walls for two residents without physician orders or informed consent, restricting their movement.
A facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, as required by policy. The resident, with chronic respiratory failure, depression, and atrial fibrillation, had orders for oxygen therapy, psychotropic medications, and an anticoagulant. However, no baseline care plans were created for these treatments, as confirmed by interviews with the RN and DON. This oversight had the potential to delay care and treatment, decreasing the resident's quality of life.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident had medications at the bedside without approval, another used bed rails without a care plan, and two residents' ADL care plans were not followed. Additionally, care plans for medication use, including Mirtazapine and insulin, were not developed, risking delays in care.
The facility's nursing staff failed to rotate injection sites for insulin and enoxaparin for two residents, leading to potential adverse effects. Resident 70 and Resident 75 received repeated injections in the same areas, contrary to facility policy and professional standards. This oversight was confirmed by the nursing staff and the Director of Nursing, who acknowledged the risk of tissue damage.
The facility failed to ensure a safe environment and proper medication management for several residents. Fall mats were compromised by heavy furniture, increasing injury risk. Medications were left unattended at bedsides, despite residents not being approved for self-administration, posing risks of medication errors. Additionally, a wet floor was left unattended, creating a slip hazard. These actions violated facility policies and compromised resident safety.
A facility failed to document pre and post dialysis weights for a resident with ESRD, as required by their care plan. The resident had an order for weights to be taken on dialysis days, but the facility only recorded weights sporadically. Interviews with the MDSD and DON confirmed the lack of documentation in the MAR or weight summary, contrary to facility policy.
The facility failed to properly assess and manage bed rail use for several residents, leading to potential safety risks. Residents with cognitive impairments and high fall risks were observed with bed rails up despite evaluations indicating they were not needed. The facility did not conduct necessary assessments, obtain informed consent, or maintain proper documentation, as confirmed by the DON.
A resident in an LTC facility experienced significant medication errors due to the failure to rotate subcutaneous injection sites for insulin and enoxaparin. Despite facility policies requiring site rotation to prevent adverse effects, records showed repeated injections in the same areas. Staff interviews confirmed the oversight, which was not in line with professional standards.
The facility failed to ensure proper training and evaluation of kitchen staff, resulting in deficiencies in food safety and sanitation. Observations revealed cracked racks, unclean equipment, and improper hand hygiene practices, posing a risk of cross-contamination. Additionally, the facility did not adhere to prescribed menus, leading to inappropriate food substitutions and serving unsuitable food textures for residents with dietary restrictions. Furthermore, the facility failed to maintain an accurate allergy list for a resident, risking exposure to allergens.
The facility failed to follow the prescribed menu and portion sizes, affecting the nutritional needs of residents. Staff served pork BBQ without weighing portions, impacting a resident with diabetes. The cook deviated from the baked beans recipe, substituting ingredients without approval. Additionally, a resident did not receive gravy with mashed potatoes as per the menu. These actions led to potential nutritional deficiencies and resident dissatisfaction.
The facility failed to maintain appropriate food temperatures during breakfast service, affecting 138 residents, including one with end-stage renal disease. Observations showed food temperatures outside recommended ranges, confirmed by the Dietary Supervisor. A resident expressed dissatisfaction with cold food, impacting her desire to eat. Facility policies on food temperature were not followed, as noted by the DON.
The facility failed to provide food in a form designed to meet the needs of residents on a soft mechanical-chopped diet, as evidenced by the serving of hard biscuits to residents who required soft, chopped, or ground consistency foods. This included a resident with severe cognitive impairment and no teeth, who was unable to consume the hard biscuit provided. The Assistant Dietary Supervisor and Registered Dietitian acknowledged the error, which contradicted established dietary guidelines.
The facility failed to maintain sanitary conditions in the kitchen, with dust on refrigerator vents, chipped and rusted racks, ice buildup in the freezer, and improper jewelry use during food preparation. Additionally, a mixer had dried food residue, and chopping boards were scratched and sticky, posing contamination risks to 138 medically compromised residents.
The facility lacked a comprehensive policy for the storage of food brought by family and visitors, failing to include guidelines on shelf life and lacking a designated refrigerator. Interviews with staff, including the DON and Dietary Supervisor, revealed uncertainty and lack of training regarding the policy, posing potential risks of food spoilage and foodborne illnesses.
The facility failed to maintain the trash area free from debris, including trash, plastic cups, and soiled gloves, around the dumpster. This was observed during a survey when kitchen staff were disposing of trash. The Environmental Service Director acknowledged the unclean state, despite monthly power washing. The facility's policies require daily inspections and cleanliness to prevent attracting pests, posing a potential infection risk to residents.
A LTC facility failed to maintain an effective infection control program, leading to deficiencies such as unlabeled urinals, improper handling of nebulizer and oxygen tubing, misuse of Hoyer lift slings, and inadequate laundry procedures. These issues posed risks of cross-contamination and infection among residents.
Incomplete Abuse Investigations Due to Missing Staff Interviews and Statements
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse investigation policy by not fully interviewing or obtaining written statements from all staff assigned to residents involved in alleged resident-to-resident physical abuse incidents. For Resident 1, who was admitted with encephalopathy, unspecified dementia, and generalized muscle weakness and had moderately impaired cognitive skills, a Change of Condition Evaluation (CIC) dated 2/15/2026 documented that Resident 1 received physical contact from Resident 2. RN 1 witnessed and separated the residents and completed a head-to-toe assessment with no pain or injuries noted. The Director of Staff Development (DSD) stated that on that date RN 1, LVN 2, and CNA 2 were assigned to Resident 1. The Director of Nursing (DON) reviewed the facility’s staff interview document dated 2/15/2026 and confirmed that it contained statements from RN 1, two clinical students, and one clinical instructor, but there were no statements from LVN 2 or CNA 2, despite their assignment to Resident 1. For Resident 2, who was admitted with ESRD, COPD, and hypertension, the MDS and History and Physical indicated intact cognitive skills and capacity to understand and make decisions. A CIC dated 2/15/2026 documented that RN 1 witnessed Resident 2 make physical contact with Resident 1, separated them, and assessed Resident 2 with no pain or injury. The facility’s Five-Day Investigation Summary indicated that staff witness statements were reviewed. The DSD stated that on 2/15/2026, RN 1, LVN 1, and CNA 5 were assigned to Resident 2. However, upon review of the staff interview document dated 2/15/2026, the DON confirmed that only statements from RN 1, two clinical students, and one clinical instructor were present, and there were no statements from LVN 1 or CNA 5, even though they were assigned to Resident 2. For Resident 3, admitted with acute kidney failure, difficulty in walking, and generalized weakness, the MDS and H&P indicated intact cognitive skills and decision-making capacity. A CIC dated 2/16/2026 documented that Resident 3 maneuvered an electric motorized wheelchair in the activity room, and the wheelchair made contact with Resident 4’s wheelchair, after which Resident 4 turned, extended an arm toward Resident 3, and made physical contact. Staff intervened, separated the residents, and assessed them with no visible injury and no pain reported. CNA 4 stated she was assigned to Resident 3 and was with another resident when the incident occurred. LVN 3 stated she was informed that her resident (Resident 3) hit Resident 4 in the right shoulder. The DSD stated that RN 1, LVN 3, and CNA 4 were assigned to Resident 3 on 2/16/2026. The DON reviewed the staff interview document and confirmed it contained a statement from LVN 3 but no statement from CNA 4, despite her assignment to Resident 3. For Resident 4, admitted with acute embolism and thrombosis of a deep vein of the left lower extremity and hypertension, the H&P indicated capacity to understand and make decisions. A CIC dated 2/16/2026 documented that Resident 4 extended an arm toward Resident 3 and made physical contact, and that Resident 3 hit Resident 4’s left knee on the table. RN 1 offered pain medication, which Resident 4 refused, and assessed Resident 4 with no visible injuries. LVN 4 stated he was assigned to Resident 4 but was not in the activity room when the incident occurred and that RN 1 informed him of the incident; he stated he checked Resident 4 and found no pain or injury. The Activity Director reported that Activity Staff 1 observed Resident 4’s wheelchair bump into Resident 3’s wheelchair in the activity room. The DSD stated that RN 1, LVN 4, and CNA 3 were assigned to Resident 4 on 2/16/2026. The DON reviewed the staff interview document and confirmed that no staff statements were documented for this incident and specifically that there were no statements from LVN 4 or CNA 3. Review of the facility’s policy and procedure titled “Abuse Investigation and Reporting,” last reviewed 4/2025, showed that the individual conducting the investigation must, at a minimum, interview staff members on all shifts who had contact with the residents during the period of the alleged incident, interview roommates, family members, and visitors, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further states that witness statements are to be obtained in writing, signed, and dated, either written by the witness or obtained by the investigator. The DON stated that, based on this policy, the investigations were not complete. The Administrator stated that for the allegations on 2/15/2026 and 2/16/2026, she interviewed RN 1 and Activity Staff 1 but did not interview the assigned staff for the involved residents, and acknowledged that the investigations for Residents 1, 2, 3, and 4 were incomplete.
Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one sampled resident by inaccurately documenting medication administration while the resident was hospitalized. The resident had been admitted with diagnoses including other encephalopathy, unspecified dementia, and generalized muscle weakness, and had multiple active physician orders for medications such as atorvastatin, levothyroxine, docusate, ferrous sulfate, lubiprostone, pantoprazole, quetiapine, and senna. The resident’s Minimum Data Set indicated moderately impaired cognitive skills for daily decisions. Record review showed that the resident was transferred to a general acute care hospital on 2/15/2026 at 7:20 p.m. following an incident in which another resident made physical contact; a head-to-toe assessment revealed no pain or injuries, and the physician ordered transfer for further evaluation. Progress notes documented the transfer on 2/15/2026 and the readmission from the hospital on 2/19/2026 at 3:02 p.m., confirming that the resident was not present in the facility between those dates and times. Despite the resident’s absence, the February 2026 Medication Administration Record showed that LVN 6 documented administration of atorvastatin, quetiapine, senna, docusate, ferrous sulfate, pantoprazole, and lubiprostone on specific dates and times while the resident was at the hospital, and LVN 7 documented administration of levothyroxine and pantoprazole during the same period. In interviews, the ADON confirmed that the resident was at the hospital during these documented administrations and stated that LVN 6 and LVN 7 should have verified the resident’s presence and identity before documenting medication administration, acknowledging that the medical record was inaccurate. The DON also stated that the nurses should not have documented medication administration when the resident was at the hospital and that medications should have been documented as not given, noting that the inaccurate medical record could cause confusion in care. The facility’s charting and documentation policy required that all medications and care be documented promptly and accurately according to facility and regulatory requirements. These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.
Failure to Care Plan for Resident’s Refusal of Hyperkalemia Medication
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a person-centered comprehensive care plan related to a resident’s refusal of ordered medication. The resident was admitted with diagnoses including end stage renal disease, COPD, and essential hypertension. An MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact, and a subsequent H&P stated the resident had the capacity to understand and make decisions. A physician’s order directed administration of Lokelma 10 grams orally on specific days for treatment of hyperkalemia. The MAR for the relevant month showed that on 2/1/2026 the resident refused the ordered Lokelma dose. During concurrent record review and interview, the ADON confirmed there was no care plan addressing the resident’s refusal of Lokelma and acknowledged that the nurse should have notified the physician and documented the refusal. The ADON stated that without a care plan for the refusal, there would be no intervention to correct the resident’s hyperkalemia and this could potentially cause further increase in potassium levels. In a separate interview, the DON stated that a care plan should have been developed for the resident’s medication refusal to create a new treatment plan to prevent further elevation of potassium, and that without such a care plan the resident’s hyperkalemia might not be corrected. The facility’s comprehensive care plan policy indicated that a CCP is to be developed for each resident to ensure individualized, resident-centered care addressing medical needs and updated based on resident conditions and preferences, which was not followed in this case.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the day of the incident, two residents sharing a room were involved in a physical altercation. One resident, who had a history of behavioral and emotional challenges, became upset after his roommate had a bowel movement on his own bed and threatened to do the same on the other resident's bed. The upset resident then pushed his roommate in the back with three fingers, causing the roommate to fall to the floor in a semi-sitting position, leaning on his right side. The resident who was pushed had multiple diagnoses, including schizoaffective disorder, major depressive disorder, and osteoarthritis, and required moderate assistance with several activities of daily living. The resident's cognitive functioning was moderately impaired. The resident who did the pushing had intact cognitive functioning but a documented history of verbal disagreements with his roommate. Multiple staff members, including an LVN and an RN, confirmed that the incident was an act of physical abuse and recognized the potential for injury. The incident was witnessed and reported by another resident and staff, and both residents involved admitted to their actions during interviews. The facility's abuse prevention policy, which maintains zero tolerance for abuse, was not upheld in this instance, as the resident was subjected to physical abuse by another resident while under the care of the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Notify Physician of Inability to Provide Ordered Speech Therapy and Resident's Ongoing Swallowing Difficulties
Penalty
Summary
The facility failed to notify the attending physician when a resident did not receive a physician-ordered speech therapy (ST) and swallow evaluation due to the absence of a speech-language pathologist (SLP) in the building. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, dementia, and depression, was admitted with significant swallowing difficulties, including pocketing food and choking. Despite a physician's order for an ST and swallow evaluation, the service was not provided because the facility had no ST available after the therapist resigned. The Director of Rehab confirmed that the last day an ST was present was prior to the order, and the resident was discharged from ST services due to this lack of availability. Progress notes and care plans indicated ongoing monitoring of the resident's swallowing difficulties, with repeated documentation of continued pocketing and difficulty swallowing over several days. However, there was no documentation that the physician was notified about the facility's inability to provide the ordered ST evaluation or about the resident's persistent symptoms. The Director of Nursing acknowledged during interviews that there was no evidence of physician notification regarding the lack of ST services or the resident's ongoing swallowing issues. The resident's condition continued to decline, culminating in an acute change in condition where the resident was unable to eat, was coughing, and continued to pocket food, ultimately requiring transfer to a general acute care hospital. Facility policy required notification of the physician and family when changes in condition or inability to provide ordered services occurred, but this was not done in this case, resulting in a delay of care for the resident.
Failure to Implement Dietitian's Recommendations for Nutritional Supplementation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following the Registered Dietitian's (RD) recommendations. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, dysphagia, dementia, and depression, experienced weight loss over a period of time. The care plan included monitoring for signs of dysphagia and providing supplements as ordered. The physician's orders specified a regular diet with pureed texture, nectar thickened liquids, and large portion protein per meal. The RD recommended providing a magic cup supplement daily at lunch due to the resident's weight loss and variable oral intake. Despite these recommendations, the facility did not provide the recommended magic cup supplement to the resident. The Director of Nursing (DON) confirmed that the RD's recommendation was not implemented and acknowledged that this could lead to further weight loss. The facility's policy required evaluation and intervention for undesirable weight changes, including ensuring adequate calorie and protein intake, but this was not followed in this case.
Failure to Provide Ordered Speech Therapy and Swallow Evaluation
Penalty
Summary
The facility failed to provide a required Speech Therapy (ST) and swallow evaluation for a resident with a history of hemiplegia, hemiparesis following cerebral infarction, dysphagia, dementia, and depression. The resident was admitted and readmitted with these diagnoses, and care plans were in place to monitor for signs and symptoms of dysphagia, including pocketing, choking, and difficulty swallowing. On a specific date, the resident was observed to be pocketing food, and the family reported swallowing difficulties. The physician was notified and ordered a speech and swallow evaluation, as well as a calorie count. Despite the physician's order for an ST and swallow evaluation, the service was not provided because the facility did not have an ST available at the time. The Director of Rehab confirmed that the last day an ST was present was prior to the order, and the resident was discharged from ST services due to the lack of available staff. There was no documentation that the physician was notified about the inability to provide the ordered evaluation. Progress notes continued to document the resident's ongoing difficulty with swallowing and pocketing food in the days following the order. The resident's condition declined, with continued reports of difficulty swallowing, pocketing food, and eventually being unable to eat, coughing, and requiring transfer to a general acute care hospital. Staff interviews confirmed that the resident choked during feeding attempts and that the lack of ST services was known to both the Director of Rehab and the DON, but no alternative arrangements or notifications to the physician were documented. Facility policy required provision of rehabilitative services as indicated and notification of the physician and family when significant changes in condition or treatment occurred, but these were not followed in this case.
Failure to Accurately Document Calorie Counts and Maintain Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with multiple diagnoses, including hemiplegia, hemiparesis, dysphagia, dementia, and depression. Specifically, the facility did not accurately document the required seven-day calorie count on the resident's Medication Administration Record (MAR), as there was no indication that staff had signed off on this task. Additionally, discrepancies were found between the resident's Calorie Count records and Meal Intake documentation for several days, with conflicting percentages and missing entries. The Director of Nursing (DON) confirmed that the documentation was inconsistent and that the MAR should have been checked off and initialed by licensed staff to validate that the task was completed. The facility's policy and procedure on charting and documentation requires that treatments or services performed be objectively, completely, and accurately documented in the resident's medical record. However, the review revealed that the calorie count documentation did not align with the meal intake records, and the MAR was not properly completed to reflect the physician's order. The DON acknowledged these inconsistencies and the inability to validate that the required interventions were performed, resulting in inaccurate documentation of the resident's records.
Failure to Follow Infection Control Protocols for Glove Use and Linen Handling
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols by wearing gloves in the hallway after providing care to residents. Certified Nursing Assistants (CNAs) were observed exiting resident rooms while still wearing gloves and handling items such as dirty linens and transporting residents in a shower chair. These actions were directly observed by surveyors and confirmed through interviews with the involved staff, who acknowledged that gloves should not be worn in the hallway to prevent the spread of infection. One resident with hemiplegia and hemiparesis required substantial assistance with activities of daily living (ADLs), and a CNA was seen leaving the resident's room wearing gloves while carrying a plastic bag of dirty linens to the dirty linen room. Another resident with acute respiratory failure and hypoxia, who required moderate assistance with ADLs, was transported in a shower chair by a CNA wearing gloves in the hallway. A third resident, dependent on staff for ADLs and diagnosed with type 2 diabetes mellitus, had their soiled linens carried by a CNA without a plastic bag, with the CNA wearing gloves in the hallway and entering the dirty linen room. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that staff are expected to remove gloves before exiting resident rooms and perform hand hygiene to prevent infection transmission. Review of facility policies also indicated that gloves are to be discarded in the room where care is provided and that soiled linens should be placed in a plastic bag before transport. These observations and staff admissions demonstrated a failure to follow established infection control procedures, creating the potential for the spread of communicable diseases within the facility.
Plan Of Correction
F 880 F 880 F 880 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the entity reported incident no. CAo0958842 which was conducted on 4/28/25. F880 Infection Prevention and Control =E Immediate Corrective Action: • On 4/28/25, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 2, on the infection control and prevention policy, focusing on the importance of not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 3 on the infection control and prevention policy, focusing on the importance of not wearing gloves while transporting residents in a shower chair to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 4 on the infection control and prevention policy, focusing on the importance of placing soiled linens in a plastic bag prior to transporting them to the soiled linen barrel and not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/25, 4/29/25, DON and IP Nurse provided an in-service to licensed nurses and CNAs regarding the use of PPE-gloves, hand hygiene/handwashing and facility policy on transporting soiled linen to the dirty linen room or soiled linen barrel to prevent the spread of infection. Other residents affected by this deficient practice: • On 4/28/2025 and 4/29/2025, the Infection Prevention Nurse and the assistant DSD staff conducted rounds during resident care and observed staff during and after care of residents to ensure that staff were removing gloves prior to exiting the resident room were performing hand hygiene/handwashing and that CNA staff are placing soiled linen in a plastic bag when transporting soiled linens in
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when two residents, both present in the facility's smoking patio, engaged in a verbal altercation that escalated into a physical confrontation. During this unsupervised period, one resident used a knife to inflict injuries on the other, resulting in abrasions to both knees and a laceration on the left thumb that required eight stitches. The incident occurred while both residents were in their wheelchairs in the designated smoking area, and no staff were present to supervise or intervene. The resident who was injured had a medical history including dementia, schizophrenia, and depression, with documented moderate cognitive impairment and partial dependence on staff for activities of daily living. The other resident involved had diagnoses of anxiety disorder, schizophrenia, and hemiplegia/hemiparesis following a cerebral infarction, with intact cognition. The inventory of personal effects for the resident who used the knife did not indicate possession of such an item, and the facility's policies required supervision for residents with smoking privileges and prohibited weapons on the premises. Staff interviews and video surveillance confirmed that the residents were left unsupervised in the smoking patio, contrary to facility policy. The altercation was not witnessed by staff, and the physical abuse was only discovered when the injured resident approached the nursing station for assistance. Staff acknowledged that supervision was required and that the incident could have been prevented if staff had been present to monitor and separate the residents at the onset of the verbal altercation.
Removal Plan
- Resident 1 approached Nursing Station 500 for assistance. RN 1 gave first aid and called LVN 1 to attend to Resident 1. RN 1 asked Resident 1 how he got the cut and Resident 1 stated he tried to seize the knife from Resident 2. RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual of the knife.
- RN 1 initiated a change of condition on Resident 2, did a body check, noted an abrasion on Resident 2's left hand and wrist, gave first aid, and called Resident 2's primary MD who ordered transfer to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter to monitor aggressive behavior and was transferred for psychiatric evaluation and treatment.
- RN 1 initiated body assessment on Resident 1 and noted abrasions on both knees. RN 1 initiated the change of condition on Resident 1, called paramedics who arrived and transferred Resident 1 to GACH 1. RN 1 called the local police.
- Resident 1 came back from GACH 1 with eight stitches on left thumb. Resident 1 was monitored for 72 hours for fall complications and symptoms of emotional distress. Social Services staff continued wellness visits for emotional support and safety. Psychiatrist visited Resident 1 and Psychologist visited Resident 1.
- DON provided 1:1 education to RN 1 regarding facility policies for abuse prevention. DON provided 1:1 education to RN 2, CNA 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. LVN 1 will be educated prior to returning from vacation.
- Facility readmitted Resident 2 from GACH 2 and provided 1:1 sitter to monitor aggressive behavior. Social Services staff continued wellness visits to Resident 2. Psychiatrist saw Resident 2. Local police apprehended Resident 2.
- Administrator posted 'No Weapons Allowed' signs in the facility at the front entrance, facility entrance, and employee lounge, with additional postings planned.
- DSD, Administrator, DON, and Assistant Administrator provided all facility staff with in-service training for all types of abuse.
- The facility made efforts to locate the knife used by Resident 2: attempted to search Resident 2 (refused), searched the smoking patio, asked police to conduct body search (declined), searched Resident 2's room and belongings, searched trash carts and laundry area, conducted searches in all residents' rooms and belongings, searched the rooftop, reviewed video footage, and will continue exhaustive search until the knife is found. Once found, the knife will be photographed, bagged, handled with caution, and turned in to police. Notification will be sent to SSA.
- DSD, Administrator, DON, and Assistant Administrator conducted in-services to staff regarding resident-to-resident verbal altercation, separating residents to avoid escalation, recognizing potential threats, and handling situations where a weapon may be involved.
- A new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director during an emergency meeting.
- RN Mentor in-serviced the Administrator and DON on the policy and procedure for abuse, how to detect and what is the definition of abuse.
- Department head managers during routine rounds will conduct safety room checks on assigned rooms to inspect for sharp objects. Any sharp objects found will be seized and reported to the Administrator for follow-up.
- Upon admission and during quarterly IDT meetings, Social Services will educate residents and representatives about the abuse policy and the protocol of not bringing sharp objects or weapons to the facility. Any such findings will be confiscated and handed to the Administrator/DON.
- Upon returning from out on pass, if residents or representatives bring any items back to the facility, the charge nurse or RN supervisor will ask for any items to be added to the inventory list.
Failure to Supervise Residents in Smoking Patio Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to two residents in the smoking patio, resulting in a physical altercation. On the morning of the incident, both residents, who had documented histories of behavioral issues and required supervision while smoking, were left unsupervised in the designated smoking area. One resident, with diagnoses including dementia, schizophrenia, and a history of disruptive behavior, and another resident, with anxiety disorder, schizophrenia, and hemiplegia, engaged in a verbal argument that escalated to physical violence. The altercation culminated in one resident using a knife to injure the other, causing a laceration to the left thumb and abrasions to both knees. The injured resident required hospital transfer and received eight stitches for the thumb wound. The investigation revealed that staff failed to follow the facility's own policies and care plans, which required direct supervision for both residents during smoking times due to their non-compliance and risk behaviors. The smoking patio was accessed outside of scheduled smoking times, and the staff member responsible for opening the door left it unattended, allowing the residents to enter without supervision. Video surveillance confirmed that no staff were present in the smoking patio during the incident, and the area was not fully visible from the hallway, further limiting oversight. Interviews with staff and review of care plans confirmed that both residents should have been supervised while in the smoking patio, and that this supervision was not provided at the time of the incident. Additionally, the facility's inventory records did not indicate that the resident who used the knife was in possession of such an item, and subsequent searches failed to locate the weapon. The lack of supervision and failure to enforce safety protocols directly led to the altercation and injury. The facility's policies on resident safety, supervision, and smoking practices were not adhered to, resulting in a situation where residents were exposed to significant harm.
Removal Plan
- Resident 1 approached Nursing Station 500 for assistance; RN 1 provided first aid and called LVN 1 to attend to Resident 1, then checked the smoking patio for Resident 2 and the alleged knife.
- RN 1 initiated a change of condition on Resident 2, performed a body check, provided first aid, called Resident 2's primary MD, and transferred Resident 2 to GACH 2 for further evaluation; Resident 2 was assigned a 1:1 sitter.
- RN 1 initiated a body assessment on Resident 1, noted abrasions, initiated a change of condition, called paramedics, and Resident 1 was transferred to GACH 1; local police were called.
- Resident 1 returned from GACH 1 with eight stitches; Resident 1 was monitored for 72 hours for complications and emotional distress; Social Services and mental health professionals provided support.
- The DON provided 1:1 education to RN 1 regarding abuse prevention, resident supervision, and following the smoking schedule; DON provided 1:1 education to RN 2, CNA 1, and CNA 2; LVN 1 to be educated before returning from vacation.
- Resident 2 was readmitted from GACH 2 and provided a 1:1 sitter; Social Services and mental health professionals continued wellness visits; police apprehended Resident 2.
- The Administrator posted 'No Weapons Allowed' signs at facility entrances and employee lounge, with additional postings planned.
- The DSD, Administrator, DON, and Assistant Administrator provided in-service training for all staff on all types of abuse.
- The facility made multiple efforts to locate the knife, including searching Resident 2 (who refused), searching the smoking patio, requesting police assistance, searching Resident 2's room and common areas, and reviewing video footage; ongoing efforts to locate the knife will continue, and the Administrator will notify authorities if found.
- Department Heads conducted resident safety checks using the inventory of personal belongings log to identify weapons or sharp objects, obtaining consent as appropriate.
- The MDS Nurse, DON, and Activity Staff conducted 1:1 smoking observation and risk evaluation for all residents who smoke; all 18 residents identified as requiring supervision during smoking.
- A new policy and procedure for Firearms and Other Weapons was initiated and scheduled for presentation to the Medical Director.
- Department head managers will conduct safety room checks during routine rounds to inspect for sharp objects, seizing and reporting any found to the Administrator.
- Facility Department heads will conduct weekly safety checks of resident belongings for 4 weeks, then monthly for 3 months, then quarterly, using the inventory form.
- Licensed Vocational Nurses and RN Supervisors will use shift huddles with CNAs to identify resident incompatibility and potential altercations, with immediate separation and reporting as needed; updated huddle form initiated.
- During weekends, the Manager of the Day will conduct rounds every 2 hours to identify incompatibility and potential altercations, reporting findings to Administrator/DON; RN Supervisor will monitor during night shifts and holidays.
- As part of Out on Pass procedure, the receptionist and licensed nurses will check any bags or items brought into the facility by residents or representatives to ensure no weapons or contraband are brought in.
- A new policy for Firearms and Other Weapons was initiated, reviewed, and approved by the Medical Director; in-service provided to staff on policy prohibiting weapons on facility premises.
- Administrator/designee will monitor and sustain the above processes, reporting trends and issues to the QAPI committee monthly for 3 months or until 100% compliance is achieved.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to protect the confidential personal and medical information of four residents by leaving sensitive documents and electronic records unattended and accessible to unauthorized individuals. Specifically, a narcotic medication sheet containing personal information for one resident was left in a bin at the nurse station, facing the hallway, making it visible to visitors, other residents, and staff not involved in the resident's care. This was confirmed during an observation and interview with a registered nurse, who acknowledged that the information was accessible to unauthorized persons. Additionally, the clinical records of three other residents were left open and unattended on a computer at the same nurse station. The computer screen displayed these residents' clinical information and was left logged in under the credentials of a nurse from a previous shift. This allowed the information to be potentially accessed by other staff not involved in the residents' care, as well as visitors and outside agencies, as observed and confirmed by the registered nurse present at the time. The residents involved had various medical diagnoses, including type 2 diabetes mellitus, essential hypertension, muscle weakness, and anxiety disorder. Their cognitive abilities ranged from intact to moderately impaired, as documented in their Minimum Data Set assessments. The facility's own policy required that only authorized personnel with proper credentials access electronic medical records, and that safeguards be in place to prevent unauthorized access, but these procedures were not followed in the incidents described.
Failure to Ensure Timely and Documented Physician Visits
Penalty
Summary
The facility failed to ensure that required face-to-face visits by a physician or alternate visits by a nurse practitioner (NP) were conducted in a timely manner for three of four sampled residents. According to the facility's policy and federal regulations, residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Documentation for these visits was either missing or did not indicate that the required physician visits occurred as scheduled. For one resident admitted with cellulitis, type 2 diabetes mellitus, and muscle weakness, the records showed an NP visit but no evidence of a physician visit after the initial assessment. Another resident admitted with type 2 diabetes, cystitis, and depression had documentation of an NP visit at admission, but no subsequent physician or NP visits were recorded. A third resident with type 2 diabetes, hypertension, and anxiety disorder had gaps in documentation, with no attending physician or NP notes for two consecutive months. Interviews with nursing staff and the DON confirmed that there was no documented evidence of timely physician visits or progress notes in the residents' medical records. The facility's policies require timely documentation of physician visits and progress notes, but these were not present in the records reviewed, indicating that the required assessments and documentation were not completed as per policy and regulatory requirements.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for three residents, as required by federal regulations. Specifically, physician telephone orders for two residents were not dated and signed, and the attending physician did not review and sign the order summaries for three residents on a monthly basis. Additionally, one resident's medical record contained blank worksheet forms and blank consent forms that had been signed by a nurse practitioner. These deficiencies were identified through record reviews and staff interviews, which confirmed that the required signatures and documentation were missing from the residents' medical records. For one resident admitted with cellulitis, type 2 diabetes mellitus, and muscle weakness, the physician's orders for pain medications were not signed or dated, and the order summary lacked the physician's signature for the relevant period. Another resident, admitted with type 2 diabetes mellitus, cystitis, and depression, had no printed and signed order summary in the medical record, and several blank forms and consents were found with a nurse practitioner's signature. A third resident, with chronic obstructive pulmonary disease, epilepsy, and depression, also had unsigned and undated physician telephone orders, and the order summary was not signed for the required months. Interviews with nursing and health information staff confirmed that the facility's policies required timely physician review and authentication of orders, as well as complete and accurate documentation in the medical record. Staff acknowledged that the missing signatures and incomplete records had the potential to result in unapproved or inaccurate orders and care. The facility's own policies and procedures were not followed, leading to incomplete and inaccurate medical records for the affected residents.
Failure to Thoroughly Investigate Resident Altercation Involving Weapon
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents in the smoking patio, resulting in one resident injuring the other with a knife. Both residents had significant psychiatric and physical diagnoses, including dementia, schizophrenia, depression, anxiety disorder, and hemiplegia. The incident occurred when both residents, each in a wheelchair, engaged in a verbal argument that escalated to physical contact, culminating in one resident using a knife to injure the other. Video surveillance confirmed the sequence of events, and it was noted that no staff were present in the smoking patio during the altercation. The investigation into the incident was incomplete. The administrator acknowledged that she did not request surveillance footage from all available cameras to track the residents' movements after the altercation. Additionally, the location of the knife used in the incident remained unknown, as searches of the resident, the smoking patio, common areas, and the resident's room did not yield the weapon. The administrator admitted that the investigation was not thorough, and the facility's policy required all allegations to be thoroughly investigated, with supporting documents and evidence provided to the individual in charge of the investigation. The facility's failure to conduct a comprehensive investigation and to account for the weapon used in the altercation placed residents at risk for further abuse. The lack of staff supervision in the smoking patio at the time of the incident was also confirmed by video review. The administrator's statements and the documentation reviewed indicated that the facility did not meet the regulatory requirements for investigating and preventing further potential abuse during the investigation process.
Plan Of Correction
F 610 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.
Failure to Complete Accurate PASARR Level I Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Screening was properly completed for one of four sampled residents. The PASARR Level I Screening, dated 7/12/2024, indicated that the resident did not have serious mental diagnoses and did not require a Level II Screening. However, subsequent reviews of the resident's admission records, diagnosis worksheets, Minimum Data Set (MDS) assessments, and psychiatric evaluations revealed multiple mental health diagnoses, including anxiety disorder, schizophrenia, psychosis, depression, and episodes of delusions and hallucinations. The resident's admission record listed diagnoses such as anxiety disorder, schizophrenia, hemiplegia, and hemiparesis following a cerebral infarction. The MDS assessments and care plan further documented ongoing mental health issues, including anxiety disorder, depression, and psychosis. Despite these documented conditions, the initial PASARR Level I Screening did not reflect the resident's mental health status, and a Level II Screening was not initiated as required. Interviews with facility staff, including the MDS Specialist and the DON, confirmed that the PASARR Level I Screening should have been completed or updated to reflect the resident's psychiatric diagnoses. The facility's policy also indicated that a status change Level I PASARR screening should be completed if there is a change in psychiatric diagnoses or a discrepancy between PASARR and physician diagnoses. The failure to complete an accurate PASARR Level I Screening had the potential to delay necessary care and services for the resident.
Plan Of Correction
Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.
Medication Storage Policy Violation
Penalty
Summary
The facility failed to implement its policy and procedure on safeguarding prescribed medications for one of the sampled residents. Specifically, the facility did not ensure that a resident's prescribed medication was stored in the medication cart or the locked medication room. Instead, the medication was found in an unlocked drawer at the nurse station, which was accessible to unauthorized individuals. This oversight was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who confirmed that the medication should have been stored securely. The resident involved was admitted with diagnoses including type 2 diabetes mellitus, essential hypertension, and depression, and their cognitive skills were intact. During a review of the resident's medical records, it was noted that there was no physician order for the dietary supplement found in the drawer, and the LVN acknowledged that discontinued medications should be disposed of properly. The Director of Nursing also confirmed that the facility failed to adhere to its medication storage policy, which requires all drugs to be stored securely and locked when not in use.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician orders. The resident, who was admitted with diagnoses including metabolic encephalopathy, COPD, and muscle weakness, had intact cognitive skills according to the Minimum Data Set. During an observation, it was noted that the resident's medication box indicated a dosage of Atrovent inhaler that did not match the physician's orders. The medication label showed one puff every 24 hours, while the physician's orders required four puffs every 24 hours as needed for shortness of breath, wheezing, or COPD. The Licensed Vocational Nurse (LVN) confirmed that the resident had not received any dose of Atrovent since readmission from the hospital. The Director of Nursing (DON) acknowledged that the Registered Nurse (RN) did not verify the medication dosage and frequency with the attending physician, leading to the potential for the resident to receive the wrong dose. The facility's policy requires that any unclear or confusing medication orders be clarified with the attending physician before processing, which was not adhered to in this case.
Failure to Account for Controlled Substance Medication
Penalty
Summary
The facility failed to maintain a comprehensive system for pharmaceutical services, specifically in the management of controlled substances, which led to the inability to account for the whereabouts of a resident's narcotic medication. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including aftercare following surgery for neoplasm, muscle weakness, and general anxiety disorder, had a physician's order for Lorazepam, a controlled substance, to be administered at bedtime for anxiety. During an interview, a Licensed Vocational Nurse (LVN) explained the procedure for verifying narcotics counts at the start of each shift, which involves both incoming and outgoing nurses signing off on the count. However, the facility's Director of Nursing (DON) revealed that an internal investigation found that the resident's narcotic medication and the corresponding count sheet were missing, and the exact number of missing tablets could not be determined. This indicates a failure in the facility's system to track and document the handling of controlled substances accurately. The facility's policy on controlled substances mandates compliance with laws and regulations regarding the handling, storage, disposal, and documentation of such medications. The policy outlines a system for reconciling the receipt, dispensing, and disposition of controlled substances, including maintaining records of personnel access, medication administration, inventory, and destruction or return to pharmacy records. Despite these policies, the facility did not adhere to them, resulting in the unaccounted loss of the resident's medication.
Failure to Honor Resident's Preference for Self-Administration of Medication
Penalty
Summary
The facility failed to honor a resident's preference to self-administer a medication, which was identified as a deficiency affecting the resident's sense of self-worth and self-esteem. The resident, admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, had intact cognitive skills as per the Minimum Data Set. Despite the resident's preference to self-administer Trulicity, a medication for diabetes, the facility did not have an order allowing this, and the medication was administered by clinicians instead. Interviews with nursing staff revealed that the resident's preference to self-administer the medication was communicated to the registered nurse, but no assessment or care plan was initiated to evaluate the resident's ability to self-administer safely. The Director of Nursing acknowledged that the process to determine the resident's ability to self-administer should have been initiated upon learning of the resident's preference. The facility's policy indicated that residents have the right to self-administer medications if deemed clinically appropriate by the interdisciplinary team, but this process was not followed in this case.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident regarding their ability to self-administer medication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, had intact cognitive skills as per the Minimum Data Set. Despite this, the facility did not reassess the resident for self-administration of Trulicity, a medication used for diabetes management, as required by the facility's policy. The resident preferred to self-administer the medication, and a Licensed Vocational Nurse (LVN) allowed this to occur without a proper assessment or physician's order. The Director of Nursing (DON) confirmed that the facility's policy required a licensed nurse to assess and document a resident's ability to self-administer medication, which was not done in this case. The facility's policy also required the interdisciplinary team to evaluate the resident's cognitive and physical abilities to ensure it was safe and clinically appropriate for them to self-administer medications. The lack of assessment and documentation placed the resident at risk for medication administration errors, including potential infection and complications from incorrect administration.
Failure to Implement Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to create and implement a comprehensive, person-centered care plan for a resident who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension. The resident's Minimum Data Set indicated intact cognitive skills, and physician orders specified the administration of Trulicity for diabetes management. However, there was no order for the resident to self-administer this medication, and no care plan was developed to address the resident's self-administration of medication. Interviews with facility staff, including a registered nurse, a licensed vocational nurse, and the Director of Nursing, revealed that the facility did not follow its policy and procedure on self-administration of medication. The policy required an assessment of the resident's ability to self-administer medication, education, and a physician order, followed by the creation of a care plan. The absence of a care plan for self-administration of medication placed the resident at risk for inconsistent care and potential complications from incorrect medication administration.
Lack of Physician Order for Self-Administration of Diabetes Medication
Penalty
Summary
The facility failed to ensure that a resident had a physician order to self-administer Trulicity, a medication used for treating type 2 diabetes mellitus. The resident was admitted with diagnoses including type 2 diabetes, depression, and essential hypertension. The Minimum Data Set indicated that the resident's cognitive skills were intact. However, the physician orders specified that licensed nurses were to administer the Trulicity, and there was no order for the resident to self-administer the medication. Interviews with the nursing staff and the Director of Nursing confirmed the absence of a physician order for self-administration. The facility's policy and procedure on self-administration of medications require a physician order and an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications. Despite this policy, the facility did not have documented evidence of such an order or assessment for the resident in question. This oversight had the potential to create confusion in the delivery of care and services to the resident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician orders. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, depression, and essential hypertension, was allowed to self-administer Trulicity, a medication for diabetes, without a physician's order. The resident's cognitive skills were intact, as indicated by the Minimum Data Set, but there was no documented order permitting self-administration of the medication. Interviews and record reviews revealed that the resident self-administered Trulicity on multiple occasions, despite the absence of a physician's order. A Licensed Vocational Nurse confirmed that the resident preferred to self-administer the medication and did so seven out of eight times when the nurse was assigned to administer it. The Director of Nursing acknowledged that self-administration required a physician's order, which was not obtained, and that the facility failed to adhere to its policy and procedure regarding self-administration of medications. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, which was not conducted in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when an altercation occurred between two residents. On December 3, 2024, Resident 2 hit Resident 1 on the left arm, causing a scratch, after Resident 1 had wheeled herself close to Resident 2 and repeatedly said 'amen.' Resident 7, who witnessed the incident, reported that Resident 2 told Resident 1 to stop, but when Resident 1 did not, Resident 2 retaliated by hitting Resident 1. This incident was classified as physical abuse according to the facility's policy and procedure. Resident 1, admitted on April 27, 2024, had a diagnosis of saddle embolus of the pulmonary artery with acute cor pulmonale and moderate cognitive impairment. Resident 2, initially admitted on October 8, 2012, had a diagnosis of hemiplegia following a cerebral infarction and severe cognitive impairment. The facility's policy, last reviewed in April 2024, emphasizes the residents' right to be free from abuse, including physical abuse by other residents. The incident was confirmed as abuse by both a Licensed Vocational Nurse and the facility Administrator during interviews.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse within the required two-hour timeframe to the State Survey Agency, the Ombudsman, and law enforcement. This incident involved a resident who was admitted with a displaced intertrochanteric fracture of the right femur, dysphagia, and essential hypertension. The resident's cognitive skills for daily decisions were severely impaired, and they required moderate assistance for activities of daily living. On the night of the incident, the resident was reportedly rough-handled by a Certified Nursing Assistant (CNA), who allegedly hit the resident in the head with a dirty incontinent brief. The incident was initially reported by a Licensed Vocational Nurse (LVN) who heard the resident yelling and screaming. The LVN contacted a family member to translate the resident's complaints due to a language barrier. The family member relayed that the CNA was rough and had hit the resident. The LVN reported this to a Registered Nurse (RN), who failed to notify the Director of Nursing, the Administrator, or the appropriate authorities that night. Instead, the RN reported the incident the following day to the Director of Staff Development and the Assistant Director of Nursing. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that there was a delay in reporting the allegation of abuse. The facility's policy requires that any allegation of abuse be reported within two hours to initiate an investigation and ensure resident safety. The failure to adhere to this policy resulted in a deficiency, as the incident was not reported to the necessary authorities in a timely manner, potentially placing the resident at risk for further abuse.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which is a deficiency in accordance with accepted professional standards of practice. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, dysphagia, and essential hypertension. A discrepancy was noted between the resident's History and Physical, which indicated the resident had the capacity to understand and make decisions, and the Minimum Data Set, which showed the resident's cognitive skills for daily decisions were severely impaired. Additionally, the resident required moderate assistance for activities of daily living and was always incontinent of bowel and bladder functions. An incident occurred where the resident was reportedly yelling and upset, leading to a call to a family member for translation due to a language barrier. The family member translated that a CNA was rough with the resident and allegedly hit the resident in the head with a dirty incontinent brief. This incident was not accurately documented in the resident's medical record, as noted by the Assistant Director of Nursing during a review. The facility's policy requires that medical records be complete and accurate, including documentation of events, incidents, or accidents involving the resident.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. On the evening of October 17, 2024, a Certified Nursing Assistant (CNA) witnessed one resident physically assaulting another resident in their shared room. The aggressor placed an arm around the victim's neck and repeatedly punched the victim in the face while the victim was seated in a wheelchair watching television. This incident resulted in the victim sustaining swelling, bleeding, and pain in the lips. The victim, identified as having severely impaired cognition and a history of cerebrovascular disease, was admitted to the facility in September 2024. The victim's Minimum Data Set (MDS) indicated a lack of interest in activities and feelings of depression and hopelessness. The Change in Condition Evaluation documented the physical abuse and the subsequent medical response, including notifying the attending physician and applying an ice pack to the victim's swollen lip. The aggressor, admitted in March 2021, had a history of aggressive behavior and was diagnosed with conditions including encephalopathy and paranoid schizophrenia. The aggressor's care plan included interventions for managing aggressive behavior, but these measures failed to prevent the incident. Interviews with facility staff, including the CNA and the Director of Nursing, confirmed the occurrence of physical abuse and acknowledged the facility's failure to prevent it. The facility's policy on abuse prevention was reviewed, highlighting the residents' right to be free from abuse by anyone, including other residents.
Failure to Provide Safe and Homelike Environment Due to Plumbing Issues
Penalty
Summary
The facility failed to provide a safe and homelike environment for four residents due to plumbing issues in their restrooms. Residents 1, 2, and 3 were affected by clogged drains in their rooms, which were not resolved promptly. The Director of Maintenance and Maintenance Assistant attempted to unclog the drains but were unsuccessful, resulting in stagnant water in the shower rooms. This situation forced the residents to use alternative restrooms, which were not adequately prepared or communicated to them. Resident 4 was not informed that other residents were directed to use their restroom, compromising their privacy. Interviews with staff revealed a lack of communication and planning regarding the use of alternative restrooms. Certified Nursing Assistants and a Licensed Vocational Nurse were not informed about where to assist residents with their toileting needs, leading to confusion and potential privacy violations. Residents expressed inconvenience and safety concerns about using restrooms in other residents' rooms or the staff restroom, which required a code and was not accessible for those using walkers or wheelchairs. The Director of Nursing was unaware of the situation and acknowledged that the facility failed to provide a homelike environment and ensure resident safety and privacy. The facility's policy on providing a homelike environment was not followed, as residents were not offered temporary room changes or alternative solutions like commodes. The facility's failure to address the plumbing issue and communicate effectively with residents and staff resulted in a deficiency in maintaining a safe and comfortable environment.
Failure to Prevent Allergen Exposure in Resident's Meal
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to onions was not served food containing this allergen. On a specific date, the resident was served baked beans that contained onions, despite their allergy being documented in their medical records, care plan, and meal tray ticket. The resident's care plan explicitly stated that they should not be served food containing onions, and the meal tray ticket indicated the resident's dietary restrictions, including their allergy to onions. During the meal tray preparation process, the dietary staff did not adhere to the facility's policies and procedures regarding food allergies. The dietary aide announced the resident's diet and allergies, but the meal tray still contained baked beans with onions. The dietary supervisor and licensed nurses checked the meal trays for accuracy, but the presence of onions in the baked beans was not identified. The resident, aware of their allergy, did not consume the beans and expressed concern about the potential presence of onions. Interviews with the dietary staff revealed a lack of awareness about the ingredients in the baked beans, as the recipe used included onions. The cook admitted to using onion powder instead of chopped onions, which was not communicated during the initial interview. The facility's policies required that residents with food allergies be offered appropriate substitutions and that meals be prepared to prevent exposure to allergens, which was not followed in this instance.
Removal Plan
- Resident 135 was assessed by a licensed nurse for signs and symptoms of food allergies. No allergic reaction was observed.
- The DON notified Resident 135's primary physician indicating the resident was mistakenly served food containing onions.
- The Dietary Supervisor visited Resident 135 to discuss the resident's food allergies and food preferences.
- The Dietary Supervisor conducted a review of all current resident's medical records residing in the facility with noted food allergies and there were no issues found.
- The Dietary Supervisor conducted an in-service with all dietary staff on the facility's Food Allergy Policy which included implementing colored meal tray card and reviewing menu or recipe to offer substitutes addressing food allergies.
- For higher visibility, green meal tray cards indicating food allergies were created for residents with food allergies.
- Residents with food allergies were provided a green non-removable arm band with their names and food allergies.
- The Director of Staff Development provided an in-service to the licensed nurses and Certified Nursing Assistants which included the green non-removable arm bands as visual identifier for residents who have food allergies.
- The Registered Dietitian reviewed current residents' medical records to ensure food allergies are up to date.
- The Registered Dietitian conducted a one to one in-service with the Cooks and the Dietary Supervisor regarding the facility policy on food allergies, food likes or dislikes, menu, recipes, and to accommodate food item substitution to address food allergies.
- Before the breakfast service, the Registered Dietitian, the Cooks, and the Dietary Supervisor conducted kitchen huddles on menu, recipes, and meal substitution for residents with food allergies.
- A list of residents and their food allergies will be posted in the kitchen meal preparation area to allow dietary staff to easily identify all residents' food allergies. The list of residents and their food allergies will be written in English and Spanish. Identified residents with food allergies will be served alternate meals.
- The facility will implement a new menu system called Menus 2U which integrates Electronic Health Records and ensures that all new dietary orders and food allergies are automatically entered into the facility's EHR. The software will include printing of the updated diet slip for each meal by the Dietary Supervisor or designee and the dietary staff will reference the meal preparation during meal tray line, avoiding inaccuracies, and identifying allergies.
- The Dietary Supervisor or designee will conduct a daily review of all current residents' medical records to ensure that residents with food allergies are included on the allergy list visibly posted during the meal tray line process.
- The Dietary Supervisor or designee will conduct daily huddles with all dietary staff in English and Spanish to discuss current residents with food allergy to ensure meals that will be served will not contain food allergies.
- The Dietary Supervisor or designee will conduct daily meal tray audit for allergies using the Tray line Supervisory Inspection Log every breakfast, lunch, and dinner meals and every 10 a.m., 2 p.m., and 8 p.m. snacks.
- Licensed Nurses shall check meal trays for any food allergies, food dislikes, and preferences before serving the residents. Any discrepancy in accuracy on the meal prepared in comparison with the diet slip will be returned to the kitchen by the licensed nurse for correction and replacement.
- The Dietary Supervisor will conduct a review of food preferences and allergies upon admission, readmission, quarterly, and as needed. The Health Information Department will conduct an audit monthly to validate this process. Audit findings will be forwarded to the DON and to the Administrator for further follow through.
- The Registered Dietitian will conduct monthly review of residents with food allergies and update the list of residents and their food allergies as needed.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of LVN 6. LVN 6 did not knock or request permission before entering Resident 68's room and loudly stated the resident's name, which was audible from 35 feet away. This behavior was observed during a survey, and LVN 6 admitted to leaving medications at the bedside for Resident 68 to self-administer, despite knowing it was against policy. Resident 68 expressed feeling disrespected by LVN 6's actions, and other residents also reported unprofessional behavior from LVN 6 during a Resident Council interview. Additionally, the facility failed to maintain resident privacy for Resident 83. CNA 8 undressed Resident 83 in a manner that made the resident visible from the hallway, compromising the resident's privacy. CNA 8 acknowledged that the resident should have been undressed behind a privacy curtain to protect their dignity. The Director of Nursing confirmed that residents should be provided bodily privacy during personal care, and the facility's policy supports this requirement. The facility's policies on resident rights and quality of life emphasize treating residents with dignity and respect, ensuring privacy, and promoting a sense of well-being. However, the actions of LVN 6 and CNA 8 violated these policies, leading to deficiencies in the care provided to Residents 68 and 83. These practices had the potential to negatively impact the residents' psychosocial well-being and quality of life.
Failure to Conduct Restraint Assessments and Obtain Consents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the cases of three residents. For Resident 75, the facility did not complete a restraint assessment before using a sensor pad alarm, which was intended to alert staff when the resident attempted to get out of bed unassisted. The sensor pad alarm was considered a restraint because it restricted the resident's freedom of movement, yet no assessment was conducted to determine its appropriateness. Additionally, the alarm was found turned off, which could have prevented staff from being alerted to the resident's movements. In the case of Resident 116, the facility placed the resident's bed against the wall without obtaining a physician's order, informed consent, or completing a restraint assessment. This action was considered a restraint as it restricted the resident's ability to get out of bed from one side. The facility's policy required a pre-restraining assessment and informed consent, which were not obtained, and the intervention was not included in the resident's care plan. Similarly, for Resident 66, the facility placed the bed against the wall without a physician's order, restraint assessment, informed consent, or care plan. This practice was also considered a restraint, as it restricted the resident's movement. The facility's policy clearly stated that such practices are not permitted without proper assessment and documentation, which were lacking in this case.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with chronic respiratory failure, depression, and atrial fibrillation, had orders for oxygen therapy, psychotropic medications, and an anticoagulant. Despite these orders, no baseline care plans were created to address the use of oxygen therapy, Donepezil, Mirtazapine, Trazadone, and Warfarin. This oversight was identified during a review of the resident's records, including the Admission Record, Order Summary Report, and Medication Administration Record. Interviews with the Registered Nurse and the Director of Nursing confirmed the absence of baseline care plans for the resident's treatments. Both acknowledged that care plans should have been developed to provide a structured framework for addressing each intervention, including setting goals and monitoring progress. The facility's policy, last reviewed in April 2024, mandates that a baseline plan of care be developed for each resident within 48 hours of admission to meet their immediate needs. The lack of such plans had the potential to delay care and treatment, thereby decreasing the resident's quality of life.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident 102, the facility did not create a care plan for medication storage at the bedside, despite the resident having medications like gas relief medication and artificial tears eye drops at the bedside without approval for self-administration. The Minimum Data Set Director confirmed that Resident 102 was not granted approval to self-administer medications, and the Director of Nursing acknowledged the necessity of a care plan to guide staff interventions. Resident 107's care plan lacked focus on the use of bed rails, which were ordered as an enabler for mobility. The resident, who had difficulty understanding and making decisions, used the bed rails daily. The Director of Nursing stated that a care plan should have been developed to guide staff on providing interventions related to bed rail use. Similarly, Residents 17 and 23 had care plans for activities of daily living that were not implemented. Resident 17 was observed with facial hair, contrary to the care plan's interventions for personal hygiene, and Resident 23 was not dressed in personal clothing as preferred, despite having clothes available. The facility also failed to develop and implement care plans for the use of medications. Resident 66 was prescribed Mirtazapine, an antidepressant with a black box warning, but there was no care plan addressing its use. The Director of Nursing emphasized the importance of a care plan to monitor the medication's effects. Additionally, Resident 75, who had type two diabetes mellitus and was receiving insulin, did not have a care plan addressing diabetes management and insulin use. The Minimum Data Set Nurse and Director of Nursing both noted the absence of a care plan, which is crucial for evaluating intervention effectiveness and preventing delays in care.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and enoxaparin administration for two residents. Resident 70, who was admitted with type 2 diabetes mellitus and a history of surgical amputation, received insulin and enoxaparin injections without proper site rotation. The review of the resident's records from August to October 2024 revealed multiple instances where injections were administered repeatedly in the same areas, contrary to the facility's policy and procedure for insulin administration. Similarly, Resident 75, diagnosed with type 2 diabetes mellitus, generalized muscle weakness, and dementia, also received insulin injections without appropriate site rotation. The resident's medication administration records from September to October 2024 showed repeated use of the same injection sites, which was confirmed by the Minimum Data Set Nurse. The facility's policy and procedure, as well as the manufacturer's guidelines, clearly indicated the necessity of rotating injection sites to prevent tissue damage. Interviews with the Registered Nurse and the Director of Nursing confirmed the failure to rotate injection sites for both residents. The Director of Nursing acknowledged that this oversight placed residents at risk for adverse effects such as bruising and lipodystrophy. The facility's policy on adverse consequences and medication errors defined such practices as medication errors, highlighting the deviation from accepted professional standards and physician's orders.
Facility Fails to Maintain Safe Environment and Medication Management
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for several residents. For Residents 66, 75, and 114, fall mats intended to reduce injury risk were compromised by having heavy furniture placed on them, which could lead to permanent indentations and reduced effectiveness in cushioning falls. Observations revealed that bedside tables were placed on these mats, making them unstable and potentially dangerous if they were to fall on the residents. Interviews with staff confirmed that such practices were against the facility's policies and could lead to increased risk of injury. Additionally, the facility did not adequately manage medication safety for Residents 70, 80, 102, 103, and 68. Medications were found unattended at residents' bedsides, despite assessments indicating that these residents were not approved to self-administer their medications. This oversight could lead to medication errors such as overdosing or underdosing, and accidental ingestion by other residents. Staff interviews highlighted a lack of adherence to the facility's policies regarding medication storage and administration. Furthermore, Resident 96's environment was not maintained safely, as a wet floor was left unattended after a CNA provided assistance with activities of daily living. This oversight posed a slip and fall risk for the resident, who was known to be at high risk for falls. The facility's policies emphasize the importance of maintaining a hazard-free environment, yet these incidents demonstrate a failure to adhere to these standards, potentially compromising resident safety.
Failure to Document Dialysis Weights
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the facility did not document pre and post dialysis weights for a resident with end-stage renal disease (ESRD) who was dependent on renal dialysis. The resident, who was capable of understanding and making decisions, had an order for weights to be taken on dialysis days, twice a day every Tuesday, Thursday, and Saturday. However, the weight summary showed that weights were only documented on a few scattered dates, not in accordance with the prescribed schedule. Interviews with the Minimum Data Set Director (MDSD) and the Director of Nursing (DON) confirmed that the weights were not documented in the Medication Administration Record (MAR) or the weight summary as required. The facility's policy indicated that weights should be recorded in the individual's medical record, but this was not followed. The lack of documentation hindered the facility's ability to monitor the resident's weight changes, which are crucial for managing dialysis treatment effectively.
Improper Bed Rail Use and Assessment Deficiencies
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for several residents, leading to potential safety risks. For Resident 66, the facility did not discontinue the use of bed rails despite an assessment indicating they were not needed. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with bed rails up, contrary to the Bed Rail Entrapment Risk Evaluation. The Director of Nursing (DON) confirmed that the continued use of bed rails without appropriate assessment could lead to accidents such as entrapment. Similarly, Resident 90, who had severe cognitive impairment and was at high risk for falls, was observed with bed rails up despite an evaluation indicating they were not needed. The facility failed to conduct a quarterly assessment to evaluate the necessity of the bed rails and did not obtain informed consent for their continued use. The DON acknowledged that the lack of assessment and consent posed a risk of injury to the resident. For Resident 75, the facility used half side rails as a restraint without completing a restraint assessment, obtaining a physician's order, or informed consent. The resident, who had moderately impaired cognition and was at high risk for falls, was observed with the incorrect type of side rails, which were considered a restraint. The DON confirmed that the facility should have followed proper procedures to ensure the appropriateness of the intervention. Additionally, Resident 107's informed consent for bed rail use was missing from the medical record, which the DON stated was a violation of the resident's rights.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin and enoxaparin. The deficiency was identified through interviews and record reviews, which revealed that the facility did not rotate the subcutaneous injection sites for insulin and enoxaparin as required. This failure to rotate injection sites was not in accordance with the prescriber's orders, manufacturer's specifications, and accepted professional standards, leading to the classification of these actions as medication errors. The resident involved had been admitted with diagnoses including type 2 diabetes mellitus and had orders for insulin lispro, Lantus, and enoxaparin. The review of the resident's medication administration records from August to October 2024 showed multiple instances where the injections were administered repeatedly in the same areas, such as the arms and abdomen, without proper rotation. This practice was confirmed by both a registered nurse and the Director of Nursing, who acknowledged that the failure to rotate injection sites could lead to adverse effects such as bruising and lipodystrophy. The facility's policies and procedures, last reviewed in April 2024, clearly outlined the necessity of rotating injection sites to prevent such adverse effects. Despite these guidelines, the facility did not adhere to the proper administration techniques, resulting in the identified medication errors. The facility's documentation and interviews with staff highlighted the lack of compliance with established protocols, which contributed to the deficiency in care provided to the resident.
Deficiencies in Kitchen Sanitation and Dietary Management
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills, leading to several deficiencies in food safety and sanitation. Observations revealed cracked racks in the walk-in freezer, a mixer with food debris and residue, a food preparation roof rack with food splatters and buildup, and chopping boards with scratches and stains. These conditions posed a risk of cross-contamination, which could lead to foodborne illnesses among residents. Additionally, a staff member failed to perform hand hygiene after picking up a potato from the floor, further increasing the risk of bacterial transfer to food. The facility also failed to adhere to prescribed menus, as evidenced by the substitution of green peas with onions instead of seas greens without the approval of a Registered Dietitian. This improper substitution could result in residents not receiving the appropriate nutritional intake, potentially leading to weight loss. Furthermore, residents on soft mechanical diets were served bread with a hard crust, which is inappropriate for individuals with difficulty swallowing or chewing, increasing the risk of choking or inadequate food intake. Additionally, the facility did not maintain an accurate and updated allergy list for a resident, which could lead to exposure to allergens and subsequent allergic reactions. The resident's medical records and the allergy list did not match, and the resident reported being served foods they were allergic to in the past. This discrepancy highlights a failure in communication and documentation, which is critical for ensuring resident safety and preventing adverse health outcomes.
Failure to Follow Menu and Portion Sizes in LTC Facility
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes, impacting the nutritional needs of 138 out of 139 residents on regular texture diets. Staff served pork BBQ without weighing portion sizes, affecting all diets, including a resident with type two diabetes mellitus. This resident, who required a consistent carbohydrate diet, expressed dissatisfaction with the small portion sizes, indicating hunger after meals. Observations revealed inconsistencies in pork slice sizes, and the Dietary Supervisor acknowledged the absence of a weighing scale, leading to estimated portion sizes. This practice was deemed inadequate by the Director of Nursing, who highlighted the potential impact on residents' weight and hunger levels. Additionally, the facility's cook deviated from the standardized recipe for baked beans by substituting ingredients without proper authorization. The cook used pinto beans instead of pork and beans and replaced chopped onions with onion powder, based on personal preference. The Registered Dietitian did not approve these substitutions, citing concerns about potential allergens and the importance of following recipes to ensure residents receive necessary nutrients. The facility's policy mandates the use of approved recipes, which were not followed in this instance. Furthermore, the facility failed to serve gravy with mashed potatoes to a resident, as indicated on the menu. The resident expressed frustration over frequent omissions and substitutions in meals. The Dietary Supervisor and Assistant Dietary Supervisor acknowledged the oversight, which could lead to resident disappointment and potential refusal of meals. The Director of Nursing emphasized the importance of following the menu to prevent psychosocial impacts and unintended weight loss. The facility's policies require adherence to planned menus and proper tray identification, which were not observed in this case.
Deficient Food Temperature Management
Penalty
Summary
The facility failed to maintain appropriate food temperatures during breakfast service in Station Four, affecting 138 of 140 residents, including a resident with end-stage renal disease. Observations revealed that the sausage patty was served at 113°F, biscuit with gravy at 108°F, milk at 49°F, and juice at 45°F, all of which were outside the recommended temperature ranges. This deficiency was confirmed through interviews and test tray evaluations, where the Dietary Supervisor acknowledged the temperature discrepancies and their potential impact on resident satisfaction and food intake. Resident 19, who was on a consistent carbohydrate renal diet, expressed dissatisfaction with the cold food, stating it reduced her desire to eat. The facility's policies required hot foods to be held at 140°F or above and cold foods at 41°F or below, which were not adhered to during the observed meal service. The Director of Nursing also noted that improper food temperatures could affect taste and appetite, potentially leading to weight loss among residents.
Failure to Provide Appropriate Diet Texture for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs, specifically for residents on a soft mechanical-chopped diet. This deficiency was observed when residents, including Resident 135, received whole hard biscuits during lunch service, despite their dietary requirements for soft, chopped, or ground consistency foods. Resident 135, who was admitted with conditions such as chronic obstructive pulmonary disease, chronic viral hepatitis C, and essential hypertension, had severely impaired cognition and required assistance with eating. The resident's diet order specified a regular diet with mechanical soft-chopped texture, yet the meal provided included a hard biscuit, which the resident could not break or consume due to the absence of upper and lower teeth. The issue was further observed during a trayline inspection where another resident, Resident 101, also received a whole biscuit despite being on a soft mechanical chopped diet. The Assistant Dietary Supervisor acknowledged that soft mechanical diets were intended for residents without teeth and should not include hard breads. However, the menu spreadsheet incorrectly included biscuits for these diets, and the Assistant Dietary Supervisor admitted to not testing the biscuit's texture before serving. The Registered Dietitian confirmed that the facility used guidelines from the National Dysphagia Diet and the International Dysphagia Diet Standardization Initiatives, which dictate that bread on a soft mechanical diet should be a quarter-inch in size with edges removed. The facility's diet manual and recipe guidelines also specified that hard crusts should be avoided for residents with chewing or swallowing limitations. Despite these guidelines, the facility's failure to adhere to the prescribed diet texture posed a risk of choking and other complications for the residents involved.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Dust buildup was found on two vents in the walk-in refrigerator, which the Dietary Supervisor acknowledged could lead to food contamination. Additionally, five out of six blue racks in the walk-in refrigerator and one rack in the walk-in freezer were chipped, cracked, and rusted, posing a risk of contamination from particles. Ice buildup was also noted on the plastic curtains and door of the walk-in freezer, which could affect the temperature and safety of stored food. Further observations revealed that a staff member was wearing a gold bracelet while preparing food, contrary to the facility's dress code policy, which prohibits jewelry for infection control purposes. The internal parts of a mixer had dried food residue, indicating inadequate cleaning, and the roof rack in the preparation area had dirt buildup. These conditions were acknowledged by the Dietary Supervisor and Assistant Dietary Supervisor as potential sources of cross-contamination and foodborne illness. The chopping boards in the clean area were found to be scratched and sticky, which could harbor bacteria and lead to cross-contamination. The facility's policies and procedures, as well as the Food Code 2022, emphasize the importance of maintaining equipment in good repair and cleanliness to prevent contamination. These deficiencies had the potential to result in harmful bacteria growth and cross-contamination, posing a risk to the 138 medically compromised residents who received food and ice from the kitchen.
Deficiency in Policy for Storing Food Brought by Visitors
Penalty
Summary
The facility failed to have a comprehensive policy regarding the use and storage of food brought to residents by family and other visitors. The existing policy did not include guidelines on the shelf life of prepared and perishable foods, nor was there a designated refrigerator for storing such food. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility's policy lacked clarity and implementation regarding the safe and sanitary storage, handling, and consumption of food from outside sources. Interviews with various staff members, including the Dietary Supervisor, Registered Nurse, Director of Nursing, and Director of Staff Development, highlighted a lack of awareness and training regarding the policy. The Dietary Supervisor was uncertain about the existence of a designated refrigerator, while the Director of Nursing acknowledged the absence of proper storage facilities, which could lead to food spoilage and potential foodborne illnesses. The Director of Staff Development admitted that no in-service training had been conducted on this matter, indicating a gap in staff education and awareness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The trash area was not maintained free from debris, including trash, plastic cups, plastic containers, soiled gloves, and paper bags of food, which were found on the floor around the dumpster. This deficiency was noted during an observation when two kitchen staff were disposing of kitchen trash. The Environmental Service Director acknowledged the unclean state of the area and mentioned that the dumpster area was power washed once a month, but it was not clean at the time of the observation. The facility's Policies and Procedures, reviewed in April 2024, require daily inspections to ensure no debris is on the ground and that lids are closed. The trash collection area must be kept clean to prevent it from becoming a feeding ground for vermin and rodents. The Food Code 2022 emphasizes the importance of proper storage and disposal of garbage to minimize odors and prevent attracting pests. The failure to adhere to these procedures posed a potential risk of attracting birds, flies, insects, and pests, which could spread infection to the facility's residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to several deficiencies. One significant issue was the presence of unlabeled and used urinal bottles in shared resident rooms, which were not properly identified for individual use. This oversight was observed in the rooms of multiple residents, including those with conditions such as paraplegia, hemiplegia, and muscle weakness, who required assistance with personal hygiene and toileting. The lack of labeling posed a risk of cross-contamination and infection among residents. Another deficiency involved the improper handling and storage of medical equipment, such as nebulizer tubing and oxygen tubing. In one instance, a resident's nebulizer tubing was found touching the floor and not labeled with the date it was last changed, increasing the risk of bacterial contamination. Similarly, oxygen tubing for several residents was either not labeled with the date of last change or was overdue for replacement according to facility policy, potentially exposing residents to infection. Additional issues included the improper use of a Hoyer lift sling, which was intended for single-resident use but was observed being used for multiple residents, and the failure to maintain proper laundry procedures. The facility did not consistently record washer and dryer temperatures or clean lint traps, which are critical for effective disinfection. Furthermore, linen cart covers were made of porous materials, and staff were not adhering to the required disinfectant contact time, compromising the cleanliness of linens and increasing the risk of contamination.
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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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