Maple Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2625 Maple Ave., Los Angeles, California 90011
- CMS Provider Number
- 055036
- Inspections on file
- 56
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Maple Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia, major depressive disorder, seizures, and a malignant brain neoplasm was transferred to a GACH for further evaluation, but the facility failed to initiate the required seven-day bed hold in accordance with its bed-hold policy and regulatory requirements. Review of the census and transfer documentation showed no bed hold was recorded, and the BOM, who is responsible for bed holds, acknowledged accidentally discharging the resident instead of reserving the bed. The DON and ADM both confirmed that a seven-day bed hold should have been in place, while the facility’s written policy requires application of state bed-hold rules and provision of written information on bed-hold rights and payment policies prior to transfer.
The facility failed to report a resident-to-resident verbal and physical altercation to the SSA within the required 2-hour timeframe for alleged abuse. Two residents, one with dementia and severe cognitive impairment and another who was cognitively intact but legally blind and with generalized muscle weakness, engaged in an escalating interaction that became physical despite staff attempts to de-escalate. Emergency services and police were called, and one resident was transferred to a GACH for further evaluation. However, the incident was not faxed to the SSA until several hours later. During interview, the ADM acknowledged the 2-hour reporting requirement but believed the event could be reported within 24 hours due to the absence of serious bodily injury, even though facility policy required immediate reporting, not later than 2 hours, for alleged abuse.
A resident with dementia and multiple health issues was physically and verbally abused by a security guard, who struck the resident on the head and cursed at him. The incident was witnessed by a CNA and resulted in the resident experiencing pain, embarrassment, and requiring hospital evaluation. The security guard had not received required abuse prevention training, and facility leadership failed to verify this training prior to allowing him to work in the care area.
A resident with schizoaffective disorder was administered Haldol without informed consent after exhibiting aggression. The facility's policy requires informed consent for psychotropic drugs, except in emergencies, but it was not obtained within the required timeframe. Staff interviews confirmed the oversight, and the Medical Record Director verified the lack of documentation.
A resident with diabetes mellitus was administered Lantus without proper documentation of the injection site, contrary to facility policy. The MAR showed multiple entries marked as 'not applicable' for the injection site, which was confirmed as a mistake by an LVN. The DON acknowledged the error, highlighting a failure to adhere to documentation standards.
A resident with diabetes was not given their prescribed Lantus insulin for six days after readmission due to the facility's failure to reconcile medication orders. The resident's discharge summary from the hospital included the Lantus order, but it was not included in the admission orders, leading to a significant medication error.
A resident was discharged from an LTC facility without a proper review of their belongings, resulting in missing items such as hearing aids and clothing. The facility also failed to ensure that replacement hearing aids were fitted correctly, leaving the resident unable to use them. The facility's policies on safeguarding personal property and discharging residents were not followed.
A resident with severe hearing loss and dementia frequently misplaced their hearing aids, yet the facility failed to implement a care plan addressing these issues. Despite staff acknowledging the resident's forgetfulness and need for reminders, the care plan lacked interventions for managing hearing aid loss and associated risks. This oversight contradicted the facility's policy for comprehensive, person-centered care plans.
A resident with severe cognitive impairment was marked as self-responsible, despite their inability to make informed decisions. The facility failed to provide legally documented representation for decision-making, violating the resident's rights. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on representation for cognitively impaired residents.
A resident with severe cognitive impairment was not properly informed or involved in their care and treatment decisions. Despite being marked as self-responsible, the resident had no family and a case manager was notified of changes, but no legal documentation for a representative was provided. The facility's policy required such documentation, which was not adhered to.
A facility failed to conduct a background check and provide abuse training for a housekeeper, leading to a deficiency in their abuse prevention program. The oversight was discovered during a review of the employee's file, which lacked documentation of a background check and abuse training. This issue was compounded by an incident involving a resident with a care plan addressing psychosocial wellbeing related to an alleged altercation with the housekeeper.
A facility failed to provide adequate supervision for a resident with dementia and schizophrenia, who was known to wander. Despite physician orders for hourly visual checks, there was no documentation of these checks in the MAR for several months. Interviews with staff revealed confusion about monitoring frequency and documentation, and the facility's policies on resident checks were not followed, leading to increased risk of accidents.
A resident experienced a strong musty odor from a clogged shower room, causing discomfort and feelings of being unheard. The facility's kitchen also faced unsanitary conditions due to a leaking pipe, requiring staff to frequently mop the floor, disrupting their duties. These issues highlighted the facility's failure to maintain a clean and homelike environment as per their policies.
A resident reported being hit by another resident, but the incident was not reported to authorities within the required timeframe. The resident experienced pain and a cervical spasm, and the facility's policy required reporting within two hours if there was an injury. The delay in reporting led to a delay in an on-site inspection.
A resident with a history of aggressive behavior assaulted two other residents in separate incidents. The facility failed to document and report these incidents as abuse, resulting in a lack of investigation and necessary interventions. The facility's leadership acknowledged the oversight, which led to the residents being subjected to abuse and potential psychosocial harm.
The facility failed to ensure physician responses to a consultant pharmacist's recommendations for two residents. One resident's use of divalproex sodium and risperidone lacked physician justification, while another's use of quetiapine was not reevaluated despite repeated recommendations. The Director of Nursing confirmed the facility's non-compliance with policy, increasing the risk of adverse effects.
A LTC facility reported a medication error rate of 15.38%, with errors affecting three residents. An LPN administered clonazepam without a physician's order, allowed a resident to self-administer Flonase without approval, and gave Vitamin C instead of Calcium/Vitamin D to another resident. Facility policies on medication administration and self-administration were not followed, increasing the risk of medical complications.
The facility failed to manage medications properly, resulting in expired insulin pens and unlabeled latanoprost eye drops, increasing the risk of administering ineffective or harmful medications. Additionally, an opened insulin bottle was improperly stored in the refrigerator, contrary to guidelines. These deficiencies were identified during an inspection of medication carts, with staff acknowledging the errors and the potential risks involved.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency, leading to deficiencies in hand hygiene, dishwashing, and chemical sanitizer use. Staff were observed not washing hands when transitioning from dirty to clean items, stacking wet dishes, and incorrectly checking dish machine temperatures and sanitizer concentrations. These failures posed a risk of cross-contamination and unsanitized dishware, potentially leading to foodborne illness among residents.
The facility did not follow its menu guidelines, resulting in residents on a regular diet not receiving gravy on their meal trays. This was observed during a trayline inspection, where the Dietary Supervisor confirmed that gravy was only served on soft mechanical and puree diets, contrary to the menu spreadsheet. The Registered Dietitian highlighted the importance of following the menu for nutritional content. This deficiency had the potential to decrease food intake and lead to weight loss among residents.
The facility failed to maintain cold food items at safe temperatures during trayline service, risking resident dissatisfaction and health. Observations revealed cold foods like beets, cheese, tomatoes, and lettuce were in the danger zone, with temperatures between 55 F and 61 F. The Dietary Supervisor acknowledged these temperatures were unacceptable, as facility policies require food to be served at safe and appetizing temperatures.
The facility failed to ensure safe food storage and preparation, leading to potential cross-contamination and foodborne illness risks. Observations revealed issues such as uncovered trash cans, improper hand hygiene, and inadequate dishwashing practices. Refrigerators and freezers were dirty, and staff did not follow proper procedures for sanitization. These deficiencies posed a risk to residents' health.
A resident was observed self-administering Fluticasone nasal spray without an IDT evaluation or physician's approval, contrary to facility policy. The resident, diagnosed with anxiety disorder and deemed not competent to understand his medical condition, was supposed to have the medication clinician administered. An LVN allowed the self-administration based on the resident's preference, despite the lack of necessary approvals.
A resident was discharged with diagnoses of anxiety disorder and insomnia, but the facility failed to complete and transmit the required MDS assessment to CMS within the mandated timeframe. The MDS Coordinator admitted the delay, which was contrary to the facility's policy requiring timely assessments as per OBRA and PPS standards.
A facility failed to accurately complete the MDS assessment for a resident by not indicating the routine use of antipsychotic medication, Seroquel, despite it being regularly prescribed for schizoaffective disorder. The DON confirmed the error, acknowledging that the MDS should have reflected the resident's medication use, as per the facility's assessment policy.
A resident admitted with anxiety disorder and dementia did not have a complete baseline care plan within 48 hours, as required by facility policy. The resident's cognitive skills were severely impaired, and the care plan lacked general information and initial goals. Interviews revealed confusion among staff regarding the timeline for completing care plans, with the DON confirming the plan was not completed on time.
The facility failed to create individualized care plans for two residents, one with auditory and visual hallucinations and another requiring insulin administration. The absence of these care plans increased the risk of inadequate care and monitoring, as confirmed by staff interviews and facility policy reviews.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident experienced multiple falls due to an unchanged care plan, while another's hospice care plan was outdated, not reflecting current physician orders. The facility's policy requires timely updates to care plans, which was not followed in these cases.
A facility failed to provide oral care to a resident with severe cognitive impairment and multiple health issues, as required by a physician's order. The resident's Treatment Administration Record showed numerous instances where oral care was not documented over several dates. An observation revealed the resident had dry, cracked lips and a dry brown film of saliva, indicating a lack of care. The DON acknowledged documentation gaps and the potential for infection and breathing difficulties.
A resident with a history of dementia and other disorders experienced swelling and redness in the left arm due to improper dressing application. The dressing was taped too tightly, causing circulation issues. The DON confirmed the incorrect application and stressed the need for proper assessment and application of dressings.
A resident's Low Air Loss Mattress (LALM) was incorrectly set at 320 pounds instead of the prescribed 118 pounds, potentially affecting circulation and pressure ulcer prevention. The resident, at risk for skin breakdown, had diagnoses including dementia and muscle wasting. Both an LVN and the DON confirmed the error, which contradicted the facility's policy on support surfaces.
A resident at high risk for falls did not receive adequate supervision, resulting in two falls. Despite a care plan requiring frequent visual checks, there was no documentation of such checks over several weeks. Interviews with staff confirmed the need for regular monitoring, which was not adhered to, leading to the deficiency.
A facility failed to ensure a resident maintained acceptable nutritional status by not obtaining accurate weight measurements and failing to perform a nutritional assessment. The resident experienced significant weight loss, which was not reported to the RD or physician, and no further assessments were conducted after admission. Despite the weight loss being potentially beneficial, the lack of assessment and monitoring was identified as a deficiency.
A facility failed to administer oxygen at the physician-ordered flow rate for a resident with COPD. The resident was prescribed 2 liters per minute via nasal cannula, but it was observed at 1.5 liters. An LVN confirmed the discrepancy, and the DON stated the setting should match the order. The facility's policy requires verification of physician's orders for oxygen administration.
The facility failed to complete a competency evaluation for a CNA hired earlier in the year. The Director of Staff Development acknowledged the oversight during a review, despite the facility's policy requiring all nursing staff to meet specific competency requirements and participate in a competency-based training program.
A discrepancy was found in a medication cart where two residents' controlled medications were not accurately documented. The DSD admitted to administering the doses but failed to sign the Controlled Drug Record, violating facility policy and risking over-administration.
A resident was prescribed divalproex sodium for seizure disorders without sufficient documentation of a seizure disorder diagnosis. The facility failed to monitor valproic acid levels, necessary for ensuring medication safety and effectiveness. The DON acknowledged the lack of documentation and monitoring, increasing the risk of adverse effects or seizures.
A resident was prescribed risperidone for schizophrenia without sufficient documentation to support the diagnosis. The resident's MDS did not list schizophrenia as an active diagnosis, and there was no care plan for hallucinations related to risperidone use. The consultant pharmacist's recommendations for reevaluation were not addressed, and the DON confirmed the lack of evidence for the diagnosis, increasing the risk of unnecessary medication use.
The facility failed to maintain cleanliness in the dumpster area, with trash observed on the ground, potentially attracting pests and spreading infection. The Dietary Supervisor noted that trash often fell during collection, and the Housekeeping Supervisor confirmed responsibility for cleaning the area twice weekly. Facility policies require dumpsters to be closed and litter-free, aligning with the Food Code 2017.
A resident with an anxiety disorder was administered clonazepam without a documented physician's order, and the doses were not recorded in the MAR. The LVN administered the medication based on its availability and monitoring instructions in the MAR, but failed to verify an active order or document the administration, contrary to facility policy.
A resident's toilet seat was found to be loose, posing a safety hazard. The resident had informed staff, but no maintenance request was logged. Interviews revealed a communication breakdown between nursing staff and maintenance, as the issue was not reported according to facility policy.
The facility failed to maintain sanitary conditions in the kitchen when the back door was left open, allowing flies to enter. The Dietary Supervisor confirmed the door was open due to heat, and flies were observed around the trayline area, posing a risk of cross-contamination. The facility's policy requires an effective pest control program to prevent such issues.
A resident with a history of aggressive behavior threw coffee at another resident, but the incident was not reported to the appropriate authorities, delaying necessary inspections and interventions. Staff interviews confirmed the altercation, and the facility's policies on abuse prevention and reporting were not followed.
The facility failed to comply with regulations by housing six residents in rooms meant for two, as observed during a survey. A resident expressed satisfaction with the room, but the Administrator was unaware of the over-occupancy and confirmed no waiver was in place. The facility's policy requires no more than two residents per room.
The facility did not meet the required space standards for 14 resident rooms, with some rooms measuring below the minimum square footage per resident. Despite this, residents and staff reported no issues with space, and the administrator requested a waiver, stating the arrangements met residents' needs without affecting their well-being.
A resident with pulmonary histoplasmosis did not receive the prescribed itraconazole medication for over a month due to the facility's failure to follow physician orders. This lapse led to the worsening of the resident's condition, requiring prolonged hospitalization and additional treatments.
The facility failed to develop and implement a comprehensive care plan for a resident with pulmonary histoplasmosis and severe cognitive impairment. Despite the resident's diagnosis and prescribed itraconazole treatment, no care plan was created to address these needs, as confirmed by an LVN. This omission violated the facility's policy on comprehensive, person-centered care plans.
The facility failed to ensure necessary care for a resident receiving hospice services by not obtaining the most recent hospice plan of care, not ensuring hospice staff signed the sign-in sheet, and lacking communication with hospice staff. This resulted in missed hospice visits and potential delays in care.
The facility failed to protect a resident from physical abuse when one resident punched another after the latter wandered into the former's room. The incident occurred due to inadequate supervision and failure to follow care plan interventions for residents with wandering behaviors.
A resident with a history of elopement, schizophrenia, and other medical conditions eloped from the facility unnoticed due to insufficient staffing and lack of a comprehensive care plan. The resident required monitoring every 15 minutes, but on the day of the incident, only one LVN and three CNAs were available to monitor 52 residents during the 11 PM - 7 AM shift. The facility failed to develop and update a person-centered care plan specific to the resident's elopement risk, contributing to the incident.
Failure to Implement Bed-Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to implement its bed-hold policy for a resident who was transferred to a general acute care hospital (GACH). The resident was admitted with diagnoses including hemiplegia, major depressive disorder, seizures, and malignant neoplasm of the parietal lobe. A physician’s order dated 3/20/2026 authorized transfer to a GACH for further evaluation, and the discharge summary showed the resident was transferred out via medical transport the day after admission. Review of the facility census and transfer documentation on 3/24/2026 showed that no bed hold was initiated at the time of transfer. During interviews and concurrent record reviews, the DON confirmed that the census dated 3/23/2026 did not indicate a bed hold for this resident and stated there should have been a seven-day bed hold from the date of transfer. The Business Office Manager, who stated the business office is responsible for bed holds and that bed holds are indicated by placing the resident’s name as a placeholder on the census, acknowledged that the census from 3/20/2026 to 3/24/2026 did not show a bed hold and admitted to accidentally discharging the resident, calling it an oversight. The Administrator stated that once a resident is sent out, the facility should hold the resident’s bed for seven days regardless of the resident’s status of returning. The facility’s policy and procedures titled “Bed-Holds and Returns” indicated that prior to a transfer, written information must be given to the resident and representative explaining bed-hold rights and limitations, reserved bed payment policies, and details of the transfer, but the report identifies a failure to reserve the bed in accordance with this policy and regulatory requirements.
Late Reporting of Resident-to-Resident Altercation to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident altercation to the State Survey Agency (SSA) within the required two-hour timeframe for alleged abuse. On 2/6/26 at 10:47 a.m., two residents engaged in a verbal and physical altercation. Staff noted the residents speaking in elevated tones and attempted to de-escalate the situation, but one resident grabbed the other while four staff members were present. Paramedics and police were notified; both residents refused medical care from paramedics. Police arrived at 11:28 a.m. and transferred one resident to a general acute hospital at 12:18 p.m. for further evaluation. The facility’s initial report to the SSA, sent by fax, was transmitted at 4:05 p.m. the same day, more than two hours after the incident. One resident involved had diagnoses including dementia, anxiety disorder, and schizoaffective disorder, with an MDS indicating severely impaired cognitive skills and a need for varying levels of assistance with ADLs such as bathing, dressing, personal hygiene, and footwear, while remaining independent with eating, oral hygiene, and toileting hygiene. The other resident had diagnoses including legal blindness, depression, and generalized muscle weakness, with an MDS indicating intact cognition, need for set-up assistance with toileting hygiene, bathing, lower body dressing, footwear, and personal hygiene, and independence with eating, oral hygiene, and upper body dressing. During an interview and record review, the administrator acknowledged that allegations of abuse should be reported to the SSA within two hours and confirmed the 4:05 p.m. reporting time. The administrator stated the belief that, because one resident had dementia and there was no serious bodily injury, the incident could be reported within 24 hours, despite the facility’s abuse policy specifying that alleged violations involving abuse must be reported immediately, but not later than two hours, if they involve abuse or result in serious bodily injury.
Failure to Protect Resident from Physical and Verbal Abuse by Security Guard
Penalty
Summary
A deficiency occurred when a resident with dementia and multiple comorbidities was subjected to physical and verbal abuse by a facility security guard. The resident, who was not competent to understand his medical condition and used a wheelchair, became irritable after being redirected away from a restricted area. During this episode, the security guard argued with the resident, cursed at him, and struck him on the back of the head with an open palm, as witnessed by a CNA. The incident caused the resident pain, embarrassment, and resulted in a transfer to a general acute care hospital for evaluation. The facility failed to ensure that the security guard had received required abuse prevention training prior to working in the resident care area. The security guard reported not having received abuse training and only signing paperwork upon hire. The DON stated that abuse training was mandatory for all staff, including those working in resident care areas, and acknowledged that verification of the security guard's training had not been completed. The facility's policy required orientation and abuse prevention training for all staff, but this was not followed in the case of the security guard. Documentation and interviews confirmed that the resident experienced significant pain and emotional distress following the incident. The resident reported a pain level of 8 out of 10 and expressed feeling embarrassed. Progress notes and interviews indicated that the resident did not receive pain relief medication for his head injury. The facility's failure to ensure proper staff training and to protect the resident from abuse directly led to the incident and the resulting harm.
Failure to Obtain Informed Consent for Haldol Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of Haldol to a resident diagnosed with schizoaffective disorder and hypothyroidism. The resident, who was cognitively intact, was admitted to the facility and required assistance with certain daily activities. On a specific date, the resident exhibited physical and verbal aggression towards staff, prompting the psychiatrist to order a one-time administration of Haldol intramuscularly. The Medication Administration Record confirmed that the Haldol was administered before the informed consent was obtained from the resident or their responsible party. The facility's policy requires informed consent for the use of psychotropic drugs, except in emergencies where it is impractical to obtain consent. However, the policy also mandates that informed consent must be obtained within 48 hours to continue the medication. Interviews with the Director of Staff Development and a Licensed Vocational Nurse revealed that informed consent should have been obtained even for a one-time order. The Medical Record Director confirmed the absence of informed consent documentation for the Haldol administration. This oversight resulted in the resident and their responsible party not being informed of the risks, benefits, and alternatives to the treatment.
Failure to Document Injection Sites for Insulin Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, specifically regarding the administration of Lantus, a medication used to control blood sugar levels. The resident, who had a history of diabetes mellitus and required long-term insulin use, was administered Lantus subcutaneously without the injection site being recorded on multiple occasions throughout December. This lack of documentation was contrary to the facility's policy, which mandates that the method and site of administration be recorded in the Medication Administration Record (MAR). The deficiency was identified during a review of the resident's MAR, which showed entries marked as 'not applicable' for the injection site on several dates. An interview with a Licensed Vocational Nurse (LVN) revealed that the omission was a mistake, and the nurse typically alternated injection sites but failed to document them. The Director of Nursing confirmed that the MAR entries were incorrect and that the facility's policy required documentation of the injection site. This oversight had the potential to result in repeated injections at the same site, which could lead to skin damage for the resident.
Failure to Reconcile Medication Orders Leads to Missed Insulin Doses
Penalty
Summary
The facility failed to reconcile a physician's order for a resident upon their readmission, resulting in a significant medication error. The resident, who had a history of diabetes mellitus and required long-term insulin use, was not administered their prescribed Lantus 20 units subcutaneously at bedtime for six days following their readmission. This oversight occurred because the Lantus order was not included in the admission physician orders, despite being listed in the discharge summary from the general acute hospital. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for moderate assistance with daily activities. The Director of Nursing acknowledged that the Lantus should have been included in the admission orders and recognized the potential for the resident to experience hyperglycemia due to the missed doses. The facility's policy required reconciliation of medications from various sources, including the discharge summary, but this process was not followed, leading to the medication error.
Failure to Safeguard Resident's Personal Belongings and Ensure Proper Hearing Aid Fitting
Penalty
Summary
The facility failed to implement measures to prevent the loss of personal belongings for a resident, leading to a deficiency in honoring the resident's right to retain and use personal possessions. The resident, who was admitted with diagnoses including dementia and mobility issues, was discharged without a proper review of their belongings list. The facility did not ensure that all personal items were returned to the resident upon discharge, as evidenced by missing items such as hearing aids, a phone charger, a shaver, slippers, a t-shirt, and sweatpants. The facility's administrator and director of nursing acknowledged that the inventory list should have been reviewed with the resident's next of kin, but this was not done. Additionally, the facility failed to ensure that replacement hearing aids provided to the resident were appropriately fitted and functional. The resident lost their hearing aids multiple times during their stay, and although replacements were mailed to the resident after discharge, they were not fitted correctly, and the resident was unable to use them. The hearing aid center responsible for the replacement did not service the area where the resident was relocated, leaving the resident without proper hearing aids since May. The facility's policies on discharging residents and safeguarding personal property were not followed, contributing to the deficiency.
Failure to Implement Adequate Care Plan for Resident with Hearing Loss
Penalty
Summary
The facility failed to develop and implement an adequate care plan for a resident with severe hearing loss in both ears. The resident, who was admitted with diagnoses including dementia and mobility issues, required hearing aids to hear clearly. However, the care plan did not include appropriate interventions for the resident's hearing condition or address the resident's behavior of frequently misplacing hearing aids. This oversight was evident despite the resident's care plan goal of improving social interaction. The resident lost their hearing aids on two separate occasions, once in May and again in September, with the replacement aids being lost the day after they were received. The facility's staff, including the social service designee and licensed vocational nurses, acknowledged the resident's forgetfulness and the need for frequent redirection and reminders. Despite these challenges, the care plan lacked specific interventions to manage the risk of miscommunication and potential falls due to the resident's hearing impairment. Interviews with facility staff, including the director of nursing and certified nursing assistants, confirmed the absence of comprehensive interventions in the care plan. The facility's policy on care plans emphasized the need for comprehensive, person-centered plans that address identified problems and risk factors, yet this was not reflected in the resident's care plan. The failure to incorporate these elements had the potential to impact the resident's sensory experience and overall well-being.
Failure to Ensure Legal Representation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment had legally documented representation for decision-making. The resident, who was admitted with diagnoses including epilepsy, schizophrenia, unspecified psychosis, and anxiety disorder, was marked as self-responsible in the admission record. However, the resident's Minimum Data Set (MDS) indicated severe cognitive impairment, with a BIMS score of 7, suggesting the resident was not capable of making informed decisions. Despite this, consent for medications was obtained by the physician without involving the resident or a responsible party. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy regarding representation for residents with cognitive issues. The Director of Nursing was unable to provide legal documentation for the resident's representative, and the facility's policy required such documentation to be obtained. This oversight resulted in a violation of the resident's rights, as there was no legally documented representative to exercise the resident's rights and make necessary decisions on their behalf.
Failure to Inform and Involve Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment, or their representative, was informed and participated in their care and treatment. The resident, who was admitted with diagnoses including epilepsy, schizophrenia, unspecified psychosis, and anxiety disorder, was marked as self-responsible despite having severe cognitive impairment. The facility's records indicated that general consent for medical care was obtained verbally from the resident, next of kin, or decision maker, but the consent for specific medications was obtained by the physician without involving the resident or a responsible party. Interviews and record reviews revealed that the resident had no family members but had a case manager who was notified of any issues or changes in condition. Despite this, there was no legal documentation provided to designate a representative for the resident. The Director of Nursing was unsure of the facility's policy regarding residents with cognitive issues who were deemed self-responsible but require representation. The facility's policy required documentation designating a representative to exercise the resident's rights, which was not provided in this case.
Failure to Conduct Background Check and Abuse Training for Housekeeper
Penalty
Summary
The facility failed to ensure that a housekeeper, referred to as Staff 1, had proper documentation of a background check in their employee file, which is a critical component of the facility's abuse prevention program. Staff 1 was hired in January 2023, and for over a year, worked without a completed background check. This oversight was discovered during a review of Staff 1's employee file, which also lacked evidence of abuse training upon hire. The Director of Staff Development (DSD) confirmed these findings during an interview and record review on October 9, 2024. The deficiency was further highlighted by an incident involving Resident 3, who had a care plan addressing an alteration in psychosocial wellbeing related to an alleged physical altercation with Staff 1. Resident 3, admitted with diagnoses including a fracture of the left tibia, lack of coordination, and essential hypertension, was noted to have symptoms of feeling down with little interest or pleasure in activities. The facility's policy, dated April 11, 2024, required the Administrator to conduct employee background checks as part of the abuse prevention program, which was not adhered to in this case.
Failure to Monitor Resident Increases Risk of Accidents
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident known to be a wanderer, which increased the risk of accidents and injuries. The resident, who was admitted with diagnoses including dementia, schizophrenia, and anxiety disorder, required close monitoring as per the physician's order and care plan. The care plan specified visual checks every hour by alternating between licensed nurses and CNAs. However, there was a lack of documentation of these visual checks in the resident's MAR for several months, indicating that the required monitoring was not consistently performed. Interviews with facility staff, including a CNA and the Director of Nursing, revealed that there was confusion about the frequency and documentation of the monitoring. The CNA could not specify how often the resident was monitored, and the DON confirmed that there were no hourly monitoring logs available for the CNAs to complete. Additionally, the facility's policies on routine resident checks and safety supervision were not adhered to, as there was no documentation of the required checks. This lack of adherence to the care plan and facility policies contributed to the deficiency in providing adequate supervision to prevent accidents.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, odor-free, and homelike environment for one of the residents, who was cognitively intact and independent in activities of daily living. The resident experienced a strong musty odor emanating from a clogged shower room adjacent to their room, which caused feelings of disgust and nausea, especially during meals. Despite reporting the issue multiple times, the resident felt unheard as the problem persisted. The maintenance supervisor confirmed the shower drain was clogged and had been an ongoing issue, with temporary fixes failing to resolve the problem. Additionally, the facility's kitchen environment was compromised due to a leaking pipe, which resulted in water dripping from the ceiling into a bucket. This situation required kitchen staff to frequently mop the floor to prevent accidents and maintain sanitation, disrupting their regular duties. The dietary supervisor and maintenance supervisor were aware of the leak, which had been present for several days, and acknowledged the unsanitary conditions caused by the water accumulation. The maintenance supervisor indicated that the repair was a significant project that would take several nights to complete. The facility's policies and procedures emphasized the importance of maintaining a safe, clean, and homelike environment with pleasant, neutral scents. However, the presence of offensive odors and unsanitary conditions in both the resident's living area and the kitchen demonstrated a failure to adhere to these standards. The director of nursing acknowledged the importance of a homelike environment but did not provide a clear response regarding the unsanitary conditions in the kitchen.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner to the State Survey Agency, local law enforcement, and Ombudsman. The incident involved a resident who reported being hit on the back by another resident while returning a coffee cup to the kitchen. The incident was witnessed by a CNA who separated the residents and reported it to the night shift charge nurse. However, the charge nurse did not report the incident to facility leadership or the appropriate agencies within the required timeframe. The resident involved in the incident had a medical history that included lack of coordination, schizoaffective disorder, and major depressive disorder. Following the incident, the resident experienced pain and a cervical spasm, as confirmed by a radiology report. The facility's policy required that allegations of abuse be reported within two hours if there was an injury, but the report to the California Department of Public Health was made three days after the incident. The delay in reporting resulted in a delay of an on-site inspection by the State Survey Agency.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, Resident 206, who had a history of aggressive behavior and mental health disorders. On two separate occasions, Resident 206 physically assaulted other residents. On June 3, 2024, Resident 206 splashed coffee onto Resident 35, who was sitting in the activity room. Despite the incident being noted by staff, it was not documented as an allegation of abuse, nor was it reported to the appropriate authorities. This lack of documentation and reporting resulted in a failure to investigate and implement necessary interventions to prevent further incidents. On June 23, 2024, Resident 206 struck Resident 5 in the face multiple times with an open hand. This incident occurred after a verbal altercation between the two residents in the hallway. The police were called, and Resident 206 was arrested for assault. Despite the severity of the incident, the facility did not have adequate measures in place to prevent such occurrences, as evidenced by the lack of a change of condition report and insufficient monitoring of Resident 206's behavior. The facility's policies on abuse prevention and reporting were not followed, as the incidents involving Resident 206 were not properly documented or reported. The facility's leadership, including the Director of Nursing and Administrator, acknowledged the failure to report the incidents and the lack of appropriate interventions. This oversight resulted in Resident 5 and Resident 35 being subjected to abuse and potential psychosocial harm, highlighting deficiencies in the facility's ability to protect residents from harm.
Failure to Respond to Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the physician responded to the consultant pharmacist's recommendations regarding the medication regimens of two residents. For Resident 8, the consultant pharmacist recommended monitoring blood ammonia levels due to the use of divalproex sodium and reevaluating the use of risperidone. Despite these recommendations made on multiple occasions, there was no physician response or documentation justifying the continued use of these medications. Resident 8's clinical records did not indicate a diagnosis of schizophrenia or seizure disorder, which were the conditions for which these medications were prescribed. Similarly, for Resident 35, the consultant pharmacist recommended reevaluating the use of quetiapine, an antipsychotic medication, to ensure there was sufficient documentation and justification for its continued use. Despite repeated recommendations, there was no physician response or documentation provided. Resident 35 had been using quetiapine regularly since admission, and his clinical records indicated diagnoses of dementia and schizoaffective disorder. Interviews with the Director of Nursing (DON) confirmed the facility's failure to respond to the consultant pharmacist's recommendations. The DON acknowledged that the lack of response increased the risk of adverse effects for both residents, as there was no clinical justification for the continued use of these medications. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented by the facility staff or prescriber, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 15.38% due to four medication errors out of 26 opportunities. These errors affected three residents during medication administration. The errors included administering clonazepam to a resident without a physician's order, allowing another resident to self-administer fluticasone nasal spray without prior approval, and administering Vitamin C to a third resident without a physician's order while omitting a dose of Calcium/Vitamin D. Resident 45 was given clonazepam by LVN 1 without a physician's order, as there was no record of such an order in the resident's clinical record. LVN 1 administered the medication because it was recently filled by the pharmacy and available in the medication cart, despite the absence of a way to record its administration in the MAR. Resident 19, who was not competent to understand his medical condition, was allowed by LVN 2 to self-administer Flonase nasal spray, contrary to the clinician-administered order and without an evaluation for safety. Resident 35, who was also not competent to understand his medical condition, was mistakenly given Vitamin C instead of the prescribed Calcium/Vitamin D by LVN 2. The facility's policies on medication administration and self-administration were not followed, as medications were not administered according to prescriber orders, and residents were allowed to self-administer without proper evaluation and documentation. These actions increased the risk of medical complications for the residents involved.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly manage medications, leading to several deficiencies. During an inspection of Medication Cart 2, two expired insulin pens were found, one for a resident labeled with an open date of 6/1/23 and another for a different resident labeled with an open date of 6/3/24. According to the manufacturer's guidelines, these insulin pens should be discarded 28 days after opening. The Licensed Vocational Nurse (LVN) acknowledged that the expired insulin pens should have been removed and replaced, as their continued presence posed a risk of administration, potentially resulting in poor blood sugar control and subsequent medical complications. In another instance, an open bottle of latanoprost eye drops was found in Medication Cart 1 without an open date label. The manufacturer's instructions require that once opened and stored at room temperature, latanoprost must be used or discarded within six weeks. The LVN confirmed that the lack of an open date increased the risk of administering expired medication, which could lead to worsening of the resident's glaucoma or other complications. Additionally, an opened insulin bottle for another resident was improperly stored in the refrigerator, contrary to the manufacturer's recommendation to store opened insulin at room temperature. The LVN was unaware of why the insulin was refrigerated and noted that administering cold insulin could cause discomfort. The facility's policies on medication storage were reviewed, indicating that medications should be stored according to the manufacturer's guidelines, and outdated or deteriorated medications should be promptly removed.
Deficiencies in Kitchen Staff Training and Sanitation Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills, leading to several deficiencies in food and nutrition services. Observations revealed that staff were unable to verbalize when to perform hand hygiene, particularly when transitioning from handling dirty to clean items. During an observation, a dietary aide was seen touching clean dishes and putting them away without washing hands or changing gloves. The dietary supervisor was unaware of the need for hand hygiene in such situations, indicating a lack of proper training and understanding of hygiene protocols. Further deficiencies were noted in the dishwashing process. Staff failed to air dry plates and trays, stacking them while still wet, which is against the facility's policy. The dietary supervisor incorrectly stated that it was acceptable to stack wet cups, showing a misunderstanding of proper dishwashing procedures. Additionally, staff were not properly trained to check dish machine temperatures, with one dietary aide incorrectly stating the temperature requirements and another unsure of how to check the temperature at all. The facility also failed to ensure proper use of chemical sanitizers. Staff did not follow the manufacturer's guidelines for using chlorine test strips, leading to incorrect assessments of sanitizer concentration. Similarly, the process for checking quaternary ammonium sanitizer concentration was not followed correctly, with staff using water at an incorrect temperature for testing. These failures in following proper sanitation procedures had the potential to result in cross-contamination and unsanitized dishware, posing a risk of foodborne illness to the residents.
Failure to Follow Menu Guidelines for Regular Diets
Penalty
Summary
The facility failed to adhere to its established menu guidelines, resulting in a deficiency where residents on a regular diet consistency did not receive gravy on their meal trays. This oversight was identified during an observation of the trayline, where it was noted that regular consistency diet trays lacked the prescribed gravy. The Dietary Supervisor confirmed that gravy was only being served on soft mechanical and puree diets, despite the menu spreadsheet indicating that all diets, including regular consistency, should receive gravy. This inconsistency in following the menu was acknowledged by the Registered Dietitian, who emphasized the importance of serving the exact foods as per the menu for nutritional content, calories, and nutrients. The facility's policies and procedures outlined that menus are developed to meet the nutritional needs of residents, including providing a variety of foods from basic daily food groups with standard portions. Additionally, standardized recipes are to be used in food preparation, and food and nutrition services staff are responsible for inspecting food trays to ensure the correct meal is provided to each resident. The failure to include gravy as specified in the menu had the potential to decrease food intake, leading to unintentional weight loss among 39 of 45 residents, as well as affecting the taste and satisfaction of the meals provided.
Deficiency in Maintaining Safe Food Temperatures
Penalty
Summary
The facility failed to maintain cold food items at safe and appetizing temperatures during trayline service, placing 44 of 45 residents at risk. During an observation and interview with the Dietary Supervisor, it was noted that cold food items such as fresh beets with oranges, cheese, tomatoes, and lettuce were in the danger zone, with temperatures ranging from 55 F to 61 F. The Dietary Supervisor acknowledged that these temperatures were not acceptable and that cold foods should be kept at less than 40 F to ensure they are appetizing to residents. The facility's policies and procedures require that each resident is provided with a nourishing, palatable, well-balanced diet served at a safe and appetizing temperature. However, during a test tray conducted with the Dietary Supervisor, the pork carnitas tacos with shredded cheese, lettuce, and tomatoes were served at 119 F, and the fresh beets with oranges were at 55 F, further confirming the deficiency. The Dietary Supervisor admitted that the cold food temperatures were not acceptable and could lead to resident complaints.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, leading to potential cross-contamination and foodborne illness risks for residents. During a kitchen tour, it was observed that the Dietary Supervisor (DS) was not wearing a hairnet, and hairnets were not readily available at the kitchen entrance. Additionally, trash cans were uncovered, and the handwashing sink was located next to a rack of condiments without a splash guard, leading to potential contamination. Shelves in the dry storage area were too low, preventing proper cleaning and pest detection, and a blue crate with paper containers was stored on the floor. The facility's refrigerators and freezers were found to be in poor condition, with black residue and dirt buildup on vents and gaskets, and cracked and discolored shelves. The DS acknowledged that the equipment was not cleaned as required, which could lead to cross-contamination. The dishwashing process was also flawed, with staff failing to air dry dishes and using expired chlorine test strips, which could result in improper sanitization. The DS admitted that staff were not following proper procedures for checking dishmachine temperatures and sanitizer concentrations. Hand hygiene practices were inadequate, with staff failing to wash hands or change gloves after handling trash or soiled items. The DS was unaware of the need to change gloves between handling dirty and clean items. Additionally, a staff member was observed preparing food without a beard guard, contrary to facility policy. These deficiencies in hygiene and sanitation practices posed a risk of contamination and illness for the residents.
Resident Self-Administers Medication Without Approval
Penalty
Summary
The facility failed to ensure that residents do not self-administer medications without prior approval, as evidenced by an incident involving a resident self-administering Fluticasone nasal spray without an interdisciplinary team (IDT) evaluation or a physician's approval. During an observation, the resident was seen self-administering the medication, which was prepared by an LVN. The resident's admission record indicated a diagnosis of anxiety disorder, and a history and physical report noted that the resident was not competent to understand his medical condition. Furthermore, the resident's order summary specified that the Flonase nasal spray was to be clinician administered, and a self-administration evaluation indicated that the resident did not wish to self-administer medications. The LVN involved stated that she allowed the resident to self-administer the nasal spray because it was his preference, despite the lack of prior approval or a physician's order. The facility's policy requires that medications be administered safely and as prescribed, with self-administration only permitted if deemed safe by the attending physician and the IDT. The policy also mandates a comprehensive assessment of the resident's cognitive and physical abilities to ensure safety and clinical appropriateness for self-administration. In this case, there was no documentation of an IDT evaluation or physician's order authorizing the resident to self-administer the medication.
Failure to Timely Transmit MDS for Discharged Resident
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) system for a resident, which is a requirement for standardized assessment and care screening. The deficiency involved Resident 29, who was admitted with diagnoses including anxiety disorder and insomnia. The resident was discharged from the facility on March 7, 2024, and the MDS assessment for discharge was not completed until July 9, 2024, well beyond the required timeframe. During an interview and record review, the MDS Coordinator acknowledged the requirement to complete a discharge MDS within 14 days of a resident's discharge. However, the discharge MDS for Resident 29 was not completed on time, as it remained open and incomplete. The MDS Coordinator was unable to provide a reason for the delay. The facility's policy, revised in November 2019, mandates comprehensive assessments at intervals specified by OBRA and PPS requirements, which were not adhered to in this case.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment Section N for a resident, specifically regarding the routine use of antipsychotic medication. On 3/28/24, the MDS assessment for a resident with dementia and schizoaffective disorder did not indicate the resident's regular use of Seroquel, an antipsychotic medication prescribed since 5/7/24. This oversight was identified during a review of the resident's medical records, which clearly showed the ongoing prescription and use of the medication. The Director of Nursing (DON) acknowledged the error during an interview, confirming that the MDS assessment was incorrect and should have reflected the resident's regular use of antipsychotics. The facility's policy on resident assessments, revised in November 2019, mandates comprehensive assessments at intervals designated by OBRA and PPS requirements, with the resident assessment coordinator responsible for ensuring timely and appropriate assessments. The failure to accurately complete the MDS assessment could potentially impact the care planning and treatment of the resident.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including anxiety disorder and dementia, had severely impaired cognitive skills for daily decision-making. Despite being independent in various activities of daily living, the resident had a history of intermittent confusion, which could impair understanding. The baseline care plan, which should have been completed within 48 hours, was not fully developed, with general information and initial goal sections left incomplete. Interviews with facility staff revealed discrepancies in the understanding of the timeline for completing baseline care plans. A Licensed Vocational Nurse (LVN) indicated that the plan was started but not completed within the required timeframe, and the Director of Nursing (DON) confirmed that the baseline care plan was not completed upon admission. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours to address the resident's immediate needs, including initial goals based on admission orders and other relevant services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the facility did not create a care plan to address problematic behaviors associated with auditory and visual hallucinations, despite the resident being prescribed risperidone for schizophrenia. This oversight increased the risk that the psychotropic medication would not be periodically reevaluated, potentially leading to adverse effects and a decline in the resident's mental or physical condition. Another resident was admitted with diagnoses including unsteadiness on feet, major depressive disorder, and morbid obesity. Despite having a physician's order for insulin administration based on a sliding scale, the facility failed to develop a care plan with goals and interventions for insulin use. This lack of a care plan had the potential to result in inadequate care and monitoring of the resident's insulin administration, as there were no measurable objectives or timetables to meet the resident's needs. Interviews with facility staff, including the Director of Nursing and a Licensed Vocational Nurse, confirmed the absence of appropriate care plans for both residents. The facility's policies on behavioral assessment and comprehensive person-centered care plans emphasize the need for measurable objectives and timetables to meet residents' needs, but these were not implemented in the cases of the two residents, leading to deficiencies in their care.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, leading to deficiencies in their care. Resident 27, who was readmitted with conditions including anxiety, depression, and congestive heart failure, experienced a fall on 5/31/2024. Despite this incident, the care plan, which identified the resident as at risk for falls, was not updated to address the change in condition. This oversight resulted in another fall on 7/2/2024, as the care plan interventions were not adjusted to prevent further incidents. Interviews with the LVN and DON confirmed that the care plan should have been updated following the initial fall. Resident 12, who was readmitted with diagnoses including dementia and was under hospice care, had a care plan that was not updated for over 10 months. The care plan still reflected the resident being under the care of Hospice 1, despite a physician's order indicating a change to Hospice 2. This lack of update meant the care plan did not reflect the current hospice provider or the resident's specific needs. The DON acknowledged that the care plan should have been revised to ensure it was resident-specific and aligned with current physician orders. The facility's policy requires care plans to be comprehensive, person-centered, and updated when there is a significant change in a resident's condition, when desired outcomes are not met, or at least quarterly. The failure to adhere to these guidelines resulted in care plans that did not meet the residents' current needs, potentially leading to inadequate care and services.
Failure to Provide Oral Care
Penalty
Summary
The facility failed to provide oral care to Resident 12, who was readmitted with diagnoses including dementia, palliative care needs, muscle wasting, and contracture of muscle. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for assistance with oral hygiene. A physician's order required oral care every two hours to prevent oral infection. However, the Treatment Administration Record (TAR) showed multiple instances where oral care was not documented as provided over several dates in June and July 2024. During an observation on July 8, 2024, Resident 12 was found with dry, cracked lips and a dry brown film of saliva, indicating a lack of oral care. The Licensed Vocational Nurse confirmed the resident needed oral care, which was supposed to be provided frequently. The Director of Nursing acknowledged gaps in documentation and the potential for infection and breathing difficulties due to the lack of oral care. The facility's policy on mouth care emphasized the importance of keeping oral tissues moist and preventing infection, but the required care was not documented as provided.
Improper Dressing Application Leads to Resident's Arm Swelling
Penalty
Summary
The facility failed to ensure that a skin protective arm sleeve was applied to a resident, resulting in the resident's left arm swelling and turning red. The resident, who had a medical history of dementia with psychotic features, seizure disorder, and anxiety disorder, was observed with two black scabs on the left upper arm and improperly applied dressings. The dressings were hanging off and taped too tightly, causing swelling and redness. During an interview, the Treatment Nurse acknowledged that the dressing was taped too tight, which could lead to poor circulation. The Director of Nursing confirmed that the dressing was not applied correctly and emphasized the importance of following the order and assessing the dressing every shift. The improper application of the dressing put the resident at risk for poor circulation, the dressing sticking to the wound, and infection.
Incorrect LALM Settings for Resident
Penalty
Summary
The facility failed to maintain the correct settings on a Low Air Loss Mattress (LALM) for a resident, identified as Resident 12, which had the potential to lead to poor circulation and pressure injuries. Resident 12 was readmitted to the facility with diagnoses including dementia, muscle wasting, and contracture of muscle, and was at risk for skin breakdown due to incontinence and other factors. The resident's care plan and physician's orders specified the use of a LALM set to 118 pounds to promote circulation and prevent pressure ulcers. However, during an observation, the LALM was found to be incorrectly set at 320 pounds. Licensed Vocational Nurse (LVN) 1 confirmed that the LALM should be set according to the resident's weight, which was 118 pounds, and acknowledged that the incorrect setting could potentially lead to the development of pressure ulcers. The Director of Nursing (DON) also confirmed that the LALM settings were based on the resident's weight and that the incorrect setting could result in improper circulation and potential injury. The facility's policy on support surfaces emphasized the importance of proper settings to prevent skin breakdown and promote circulation.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as being at high risk for falls. This resident, who was cognitively intact but required supervision due to generalized weakness and impaired gait, experienced falls on two separate occasions. The care plan for the resident, dated May 11, 2024, included interventions such as keeping the bed in the lowest position, conducting frequent visual checks, and encouraging the use of a call light. However, from May 11 to May 31, 2024, and from June 5 to July 2, 2024, there were no documented visual checks, which were crucial for monitoring the resident's location and preventing falls. Interviews with facility staff, including an LVN and the DON, revealed that the resident was known to be at high risk for falls due to tremors and mobility issues. The LVN acknowledged that more frequent checks could have prevented the falls, and the DON confirmed that visual checks should be conducted every two hours for residents at high risk. The facility's policy on managing falls, revised in March 2018, required staff to monitor and document responses to interventions aimed at reducing fall risks. The lack of documented visual checks and supervision contributed to the resident's falls, highlighting a deficiency in the facility's adherence to its fall prevention protocols.
Failure to Monitor and Assess Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status by not obtaining accurate weight measurements and failing to perform a nutritional assessment. The resident, who was admitted with conditions including anxiety disorder, insomnia, and dementia, had a significant weight loss that was not properly monitored or addressed. The initial weight recorded upon admission was taken from a previous chart rather than verified, and subsequent weight measurements showed a consistent decline. The Licensed Vocational Nurse (LVN) did not report the resident's weight loss to the Registered Dietician (RD) or the physician, and no further nutritional assessments were conducted after the initial admission assessment. The RD acknowledged the oversight in not verifying the resident's weight and not conducting quarterly nutritional assessments, focusing only on residents with known nutritional issues. Despite the weight loss being potentially beneficial, the lack of assessment and monitoring was identified as a deficiency. The Director of Nursing (DON) confirmed that staff were required to verify weights upon admission and monitor them over time. The facility's policies required the RD to perform thorough assessments upon admission and as needed, especially for residents experiencing weight loss. However, these procedures were not followed, leading to a failure in detecting and managing the resident's weight loss effectively.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that a resident receiving respiratory care was provided with oxygen in accordance with the physician's order. Resident 48, who has a medical history of chronic obstructive pulmonary disease (COPD), was prescribed oxygen at a flow rate of 2 liters per minute via nasal cannula continuously. However, during an observation, it was found that the oxygen flow rate was set at 1.5 liters per minute. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the flow rate should be at 2 liters per minute due to the resident's COPD. The Director of Nursing (DON) also confirmed that the setting should match the physician's order of 2 liters continuous. The facility's policy on oxygen administration requires verification of the physician's order for such procedures.
Failure to Complete Competency Evaluation for CNA
Penalty
Summary
The facility failed to ensure that competency evaluations were completed for a Certified Nursing Assistant (CNA) who was part of a sample of three CNAs. This deficiency was identified through an interview and record review process. The CNA in question was hired on January 1, 2023, but did not have a completed competency evaluation in their employee file. During a concurrent interview and record review, the Director of Staff Development (DSD) acknowledged responsibility for ensuring that newly hired employees completed their competency skills evaluations. However, the DSD was unable to provide a competency skills evaluation for the CNA. The facility's policy, revised on April 11, 2024, requires all nursing staff to meet specific competency requirements as defined by state law. It also mandates that licensed nurses and nursing assistants participate in a facility-specific, competency-based staff development and training program, demonstrating necessary competencies and skill sets to care for residents. The lack of a competency evaluation for the CNA indicates a failure to adhere to this policy.
Controlled Medication Discrepancy in Medication Cart
Penalty
Summary
The facility failed to accurately account for two doses of controlled medications, affecting two residents, during an inspection of one of the medication carts. Specifically, there was a discrepancy between the Controlled Drug Record and the medication card for clonazepam and tramadol, medications used to treat mental illness and pain, respectively. For one resident, the Controlled Drug Record indicated 12 doses remaining of clonazepam, but the medication card contained only 11 doses. Similarly, for another resident, the Controlled Drug Record showed 11 doses remaining of tramadol, while the medication card had only 10 doses. During an interview, the Director of Staff Development (DSD) admitted to administering the missing doses to the residents earlier in the day but failed to sign the Controlled Drug Record at the time of administration. The facility's policy requires the nurse to sign the accountability record immediately after removing a dose from the supply to ensure accurate tracking and prevent over-administration. The DSD acknowledged that failing to document the administration of controlled medications could lead to residents receiving them more frequently than prescribed, potentially causing health complications.
Failure to Document Seizure Disorder and Monitor Medication Levels
Penalty
Summary
The facility failed to provide sufficient documentation to support a diagnosis of seizure disorder for a resident, identified as Resident 8, who was prescribed divalproex sodium for seizure disorders. Despite the prescription, there was no evidence in the clinical records, including physician or neurologist notes, indicating that the resident had a seizure disorder or had experienced seizures. The resident's Minimum Data Set assessment also did not list a diagnosis of seizure disorder. The Director of Nursing (DON) acknowledged that divalproex sodium was initially used for behavioral management and later converted to seizure disorder without proper documentation or evidence of seizures. Additionally, the facility did not perform routine monitoring of valproic acid levels, which is necessary to ensure the medication's safety and effectiveness. The care plan for the resident indicated the need to monitor labs and report any subtherapeutic or toxic results, but the facility only measured the valproic acid level once upon admission, which was too low to be effective. The DON admitted that the facility did not recheck the levels after changing the medication's indication to seizure disorder, increasing the risk of adverse effects or seizures due to improper medication management.
Lack of Documentation for Schizophrenia Diagnosis in Resident Prescribed Risperidone
Penalty
Summary
The facility failed to provide sufficient documentation to support a diagnosis of schizophrenia for a resident prescribed risperidone, a medication used to treat mental illness. The resident, who was admitted with diagnoses including encephalopathy, was prescribed risperidone for schizophrenia manifested by auditory and visual hallucinations. However, the resident's minimum data set assessment did not list schizophrenia as an active diagnosis, and there was no care plan addressing the resident's hallucinations related to the use of risperidone. Additionally, the clinical record lacked any physician or psychiatric notes confirming a diagnosis of schizophrenia. The consultant pharmacist had recommended reevaluating the use of risperidone and ensuring adequate documentation and justification for its continued use, but there was no physician response to these recommendations. During an interview, the Director of Nursing acknowledged the absence of clinical evidence supporting the schizophrenia diagnosis and the lack of documentation and care planning for the resident's condition. This deficiency increased the risk of the resident receiving antipsychotic medication longer or at higher doses than necessary, potentially leading to a decline in quality of life.
Improper Garbage Disposal and Cleanliness Issues
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the dumpster area outside the facility. On July 8, 2024, at 11:40 AM, surveyors noted plastic bottles, paper, soiled gloves, and other trash on the ground. During an interview, the Dietary Supervisor acknowledged that trash often fell from the bins during garbage collection and emphasized the importance of maintaining cleanliness to prevent pest infestations and infection spread. The responsibility for cleaning the area was attributed to the housekeeping staff. The Housekeeping Supervisor confirmed that she was responsible for cleaning the trash area, which was scheduled for every Monday and Friday. She also recognized the importance of keeping the area clean for infection control. The facility's policies and procedures, dated April 11, 2024, required that outside dumpsters be kept closed and free of surrounding litter, in accordance with state laws. Additionally, the Food Code 2017 mandates that outside receptacles for refuse be designed with tight-fitting lids and kept covered to prevent contamination.
Failure to Document Clonazepam Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident by not recording administered doses of clonazepam in the Medication Administration Record (MAR) between specific dates. The resident, who was admitted with an anxiety disorder, was observed taking clonazepam, a medication used to treat mental illness, without a current physician's order documented in her clinical record. The MAR for the specified period showed no recorded doses or ability to record doses of clonazepam, despite the medication being filled by the pharmacy. During an interview, the Licensed Vocational Nurse (LVN) admitted to administering clonazepam to the resident without verifying an active physician's order, based on the medication's availability and the MAR's instructions to monitor for adverse effects. The LVN acknowledged the oversight in not checking for an active order and failing to document the administration in the MAR, which was against the facility's policy. This practice increased the risk of medical complications for the resident.
Loose Toilet Seat Poses Safety Hazard
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for a resident due to a loose toilet seat in the resident's bathroom. During an observation, it was noted that the toilet seat was not secured, and the resident expressed difficulty in getting up from it because it was wiggly. The resident had informed the staff about the issue, but no action was taken to fix it. Interviews with the Licensed Vocational Nurse (LVN) and the Maintenance Supervisor (MS) revealed a breakdown in communication and procedure. The LVN was unaware of the issue and acknowledged it as a safety hazard, while the MS stated that maintenance requests were logged in a maintenance log, which he checked twice daily. However, no request for the loose toilet seat was found in the log, indicating that the staff had not informed the maintenance department of the issue, contrary to the facility's policy and procedure for maintaining a safe environment.
Sanitation Deficiency in Kitchen Due to Open Door
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as observed during a survey. On the morning of July 8, 2024, the kitchen's back door was found wide open, which allowed flies to enter the kitchen. The Dietary Supervisor (DS) confirmed that the door had been left open due to high temperatures in the kitchen, although it was usually kept closed. During the lunch trayline observation, a fly was seen flying around the area where residents' food was being assembled. The DS acknowledged that the fly likely entered from outside due to the open door, posing a risk of cross-contamination by potentially bringing dirt to the food. The facility's policy, dated April 11, 2024, indicated that an effective pest control program should be maintained to keep the building free of insects and rodents.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the State Survey Agency within the required timeframe, involving two residents, Resident 35 and Resident 206. This incident was not reported to the Department of Public Health, the Ombudsman, or the police, which resulted in a delay of onsite inspections and placed the residents at risk of further abuse. The Social Services Director acknowledged the incident as a reportable event but did not take the necessary steps to report it. Resident 206, who was admitted with diagnoses including schizophrenia, bipolar disorder, Parkinson's disease, and major depressive disorder, was involved in the altercation. The resident had a history of self-harm and was being monitored for aggressive behavior. On the day of the incident, Resident 206 threw coffee at another resident, Resident 35, in the activity room. Despite being aware of the incident, the Social Services Director deleted the documentation and did not report it, citing the need to add more information. Interviews with staff, including a CNA, LVN, and the Activity Assistant, confirmed the occurrence of the altercation and the lack of reporting. The Director of Nursing and the facility's Administrator also acknowledged the failure to report the incident. The facility's policies on abuse prevention and reporting were not followed, as the incident was not documented as an allegation of abuse, and no immediate investigation was conducted.
Over-Occupancy of Resident Rooms
Penalty
Summary
The facility failed to ensure compliance with federal and state requirements regarding the maximum number of residents per room. Specifically, room [ROOM NUMBER] and room [ROOM NUMBER] each housed six residents, exceeding the limit of two residents per room for new constructions after November 28, 2016. This was observed during a survey on 7/8/2024. Resident 14, one of the occupants, expressed satisfaction with the room conditions, stating he had enough space for his belongings and no complaints. However, the facility's Administrator was unaware of when or why the rooms were over-occupied and confirmed there was no room waiver in place for these rooms. The facility's policy, revised in May 2017, mandates that bedrooms must accommodate no more than two residents at a time, which was not adhered to in this instance.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 14 out of 20 resident rooms met the required space standards of 80 square feet per resident in multiple resident bedrooms. During a general tour, it was observed that rooms with three and six residents did not meet the minimum square footage requirements, with some rooms measuring as low as 220 square feet for three residents and 455 square feet for six residents. Despite the lack of space, the rooms were equipped with privacy curtains and had direct access to corridors. The deficiency was identified through observation, interviews, and a review of the Client Accommodations Analysis, which confirmed the inadequate space allocation. Interviews with residents and staff revealed that there were no complaints regarding the room sizes. Residents expressed satisfaction with the space available, indicating that they could move around comfortably and that nursing staff had sufficient room to provide care. Certified Nursing Assistants also reported that they could perform their duties without obstruction. The facility's administrator requested a waiver for the rooms, arguing that the current arrangements met the residents' special needs without adversely affecting their health and safety.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow the physician's order for administering itraconazole to a resident diagnosed with pulmonary histoplasmosis. The resident was initially prescribed itraconazole 200 mg orally three times a day for three days, followed by 200 mg orally two times a day. While the facility administered the medication correctly for the first three days, they failed to continue the prescribed dosage of 200 mg twice a day thereafter. This lapse resulted in the resident not receiving the medication from 3/23/24 to 4/24/24. The resident, who had severe cognitive impairment and required moderate assistance with daily activities, experienced a worsening of their condition due to the missed medication. A CT scan revealed the progression of histoplasmosis, leading to the resident being sent to the hospital for further treatment. The resident's histoplasmosis had spread from the lungs to the bones, necessitating prolonged hospitalization and additional treatments. Interviews with facility staff and a review of medical records confirmed the failure to transcribe and administer the medication as ordered. The facility's policies on medication ordering and administration were not followed, contributing to the resident's deteriorating health condition. The Director of Nursing acknowledged the oversight and the importance of adhering to physician orders to prevent such deficiencies.
Failure to Develop Comprehensive Care Plan for Resident with Pulmonary Histoplasmosis
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with pulmonary histoplasmosis. The resident, who had severe cognitive impairment and required moderate assistance with various activities of daily living, was admitted initially on 6/29/23 and readmitted on a later date. Despite the resident's diagnosis and the prescribed medication regimen of itraconazole, the facility did not create a care plan addressing the pulmonary histoplasmosis or the medication. This omission was confirmed during an interview with an LVN, who acknowledged the absence of the necessary care plan and stated that it should have been created to outline the plan of care and monitor the effects and adverse effects of the medication. The facility's policy on comprehensive, person-centered care plans, reviewed on 1/11/24, mandates that such care plans include measurable objectives and timeframes, describe the services to be furnished, reflect treatment goals, and aid in preventing or reducing decline in the resident's functional status. The failure to develop and implement a care plan for the resident's pulmonary histoplasmosis and itraconazole treatment resulted in the facility not meeting the resident's needs to help attain their highest practicable well-being.
Failure to Ensure Consistent Hospice Care
Penalty
Summary
The facility failed to ensure necessary care was consistently provided for a resident receiving hospice services. The hospice agency staff did not sign the hospice sign-in sheet, and the facility did not obtain the most recent hospice plan of care. Additionally, there was a lack of communication between the facility staff and the hospice staff, which resulted in the resident not receiving the required hospice visits. The charge nurse and Social Services Director (SSD) confirmed that the hospice binder did not include an updated hospice care plan and that the hospice staff visit sign-in sheet did not reflect the required number of visits. The Director of Nursing (DON) acknowledged that the facility staff should have been communicating with the hospice staff during their visits and should have been informed of the visit schedule. The resident involved had multiple diagnoses, including dementia, dysphagia, failure to thrive, and abnormalities of gait and mobility. The resident was admitted to hospice care, but the facility failed to ensure that the hospice staff visited as scheduled and that the hospice care plan was updated. This lack of coordination and communication had the potential to result in a delay of care and a lack of coordination in the delivery of hospice care and services to the resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. On 4/20/2024, Resident 1 punched Resident 2 in the face after Resident 2 wandered into Resident 1's room. This incident occurred because CNA3, who was assigned to monitor Resident 2, left the resident unsupervised. Resident 1 had a history of aggression as indicated in their care plan, but no recent physical or verbal behavioral symptoms were noted. Resident 2 had a history of wandering and was supposed to be checked every hour and visually checked every 15 minutes, but these interventions were not adequately followed on the day of the incident. Resident 1 was admitted with diagnoses including chronic obstructive pulmonary disease, dementia, and bipolar disorder, and had moderately impaired cognition. Resident 2 was admitted with diagnoses including diabetes type 2, dementia, and schizoaffective disorder, and had difficulty focusing attention and disorganized thinking. On the day of the incident, CNA4 observed Resident 2 quickly moving towards Resident 1's room and tried to redirect him but was unsuccessful. Resident 1 then punched Resident 2, who fell to the floor. CNA4 called for help, and CNA3, who was at the nursing station doing charting audits, came to assist. The Director of Nursing (DON) stated that CNAs responsible for monitoring residents should not be performing other duties such as charting audits. Additionally, it was noted that it is best practice not to send two CNAs on break simultaneously to ensure effective monitoring of residents with wandering behaviors. The Minimum Data Set Nurse (MDSN) confirmed that no new interventions were implemented after a previous wandering episode involving Resident 2 on 4/11/2024, which was required to monitor the effectiveness of the care plan interventions. The facility's policies on wandering, elopement, and abuse prevention were not adequately followed, leading to the incident of resident-to-resident abuse.
Elopement Incident Due to Inadequate Supervision and Staffing
Penalty
Summary
The deficiency identified in the report pertains to the failure of a long-term care facility to prevent elopement of a resident who was at risk due to a history of elopement, inability to understand, and a diagnosis of schizophrenia and other medical conditions. Despite the resident being identified as at risk for elopement and requiring monitoring every 15 minutes, the facility did not have a comprehensive care plan in place to ensure adequate supervision. On the day of the incident, there was a lack of staffing during the 11 PM - 7 AM shift, with only one LVN and three CNAs responsible for monitoring 52 residents, leading to the resident eloping from the facility unnoticed. The report highlights that the facility's deficiencies included the failure to develop a person-centered care plan specific to the resident's elopement risk, review and update the care plan as required, and ensure adequate staffing for monitoring high-risk residents. Despite previous interventions and plans in place to prevent elopement, such as visual checks every 15 minutes, the facility did not effectively implement these measures on the day of the incident. The lack of designated staff to monitor residents at risk for elopement, particularly during critical times like early morning hours, contributed to the resident being able to leave the facility undetected.
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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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