Marina Pointe Healthcare & Subacute
Inspection history, citations, penalties and survey trends for this long-term care facility in Culver City, California.
- Location
- 5240 Sepulveda Blvd, Culver City, California 90230
- CMS Provider Number
- 555340
- Inspections on file
- 44
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Marina Pointe Healthcare & Subacute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, right-sided hemiplegia/hemiparesis, and total dependence for ADLs was transferred to a GACH for hypotension, desaturation, and other acute symptoms, where imaging revealed a subacute displaced fracture of the right humerus. The hospital social worker reported the fracture to the facility, and the family later questioned the DON and DOR about how the fracture occurred, but facility leadership stated they were unaware of any fall or injury. Despite its policy requiring that unusual occurrences threatening resident welfare be reported to CDPH within 24 hours, the facility did not report the fracture because staff did not know how it happened, resulting in a failure to follow mandated unusual occurrence reporting procedures.
A resident with right-sided hemiplegia, severe cognitive impairment, and total dependence for ADLs repeatedly exhibited pain behaviors when staff moved the right arm during care. CNAs reported the pain to charge nurses, and a family member posted a note above the bed asking staff to be careful with the painful arm. An LVN saw the note, briefly checked the arm for swelling or redness, but did not fully assess range of motion, complete a COC, contact the family, or notify the physician. The resident was later sent to a GACH for a change in condition, where imaging showed a displaced fracture of the right humerus. The DON and DOR reported they were unaware of any fall or injury, and the DON acknowledged only a verbal inquiry was done, without the written investigation and incident reporting required by facility policy. These failures led to the resident’s arm pain not being timely assessed, the MD not being notified, and pain interventions not being provided.
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for multiple ADLs did not have a care plan addressing pain management, mobility deficits, or ADL care, despite PT and OT documentation of poor sitting balance and need for maximal assistance. CNAs reported the resident consistently moaned and said "ouch" when the right arm was moved during dressing and other care, and a family member posted a note above the bed asking staff to treat the weaker, painful side with care. The MDS nurse and DON acknowledged that required care plans for mobility, ADLs, and pain had not been developed, even though facility policy called for comprehensive, person-centered care plans with measurable objectives and timetables.
A resident with right-sided hemiplegia, severe cognitive impairment, and multiple contractures repeatedly showed and voiced pain with movement of the right arm during ADL care, but CNAs did not complete required Stop and Watch forms and only verbally reported concerns to various nurses without clear follow-through. An LPN observed facial grimacing with repositioning but did not treat it as a change in condition, and another LPN saw a family-posted note instructing staff to be careful with the resident’s painful right arm yet did not assess the arm, contact the family, notify the physician, or complete a change of condition report. The facility’s pain assessment and management policy, which required systematic assessment, documentation, and intervention for acute or worsening pain, was not implemented, resulting in delayed assessment, physician notification, and pain management, and the resident was later found at the hospital to have a right shoulder fracture.
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during high-contact ADL care for two residents on EBP. In both cases, an isolation cart and EBP signage were posted at the room entrances, but CNAs entered and provided care without wearing required isolation gowns. Each resident had severe cognitive impairment, was dependent for ADLs, and had complex medical conditions including chronic respiratory failure and ventilator dependence; one also had COPD and the other had Parkinson disease with GT and trach. Care plans and, for one resident, physician orders directed implementation of EBP for incontinence and other high-contact care, and facility policy required staff to don gowns and gloves before such activities. During interviews, the CNAs acknowledged that the signage meant gowns should be worn for infection control, and an LVN confirmed that EBP includes use of gowns and gloves before providing care.
A resident with respiratory failure, pneumonia, a tracheostomy, and ventilator dependence had incomplete and inaccurate documentation of respiratory assessments and change in condition. An LVN assessed the resident’s breath sounds but left the breath sound section of the Licensed Nurse Record blank and did not chart the findings in progress notes. A respiratory therapist documented a progress note with a time that conflicted with the time recorded on a change-of-condition form and the EMS run sheet, and leadership confirmed the documentation times were inaccurate and the record confusing. These actions and omissions resulted in an inaccurate and incomplete medical record.
Three residents were allowed to go out on pass without proper documentation specifying whether they required accompaniment or the duration of their leave, and staff failed to assess and document their condition before and after leaving, contrary to facility policy. The DON confirmed that required procedures for OOP orders and resident assessments were not followed.
Three residents with significant cognitive and physical impairments were transferred to hospitals without receiving the required written notices about bed-hold policies or transfer/discharge, as mandated by facility policy. The DON confirmed that there was no process in place to provide these notifications, resulting in residents and their representatives not being informed of their rights.
A resident with a tracheostomy and complex care needs was transferred to a hospital for a planned procedure, and although a 7-day bed-hold was requested and ordered, the facility failed to hold the original sub-acute bed. Instead, the bed-hold was moved to a skilled nursing unit room that could not accommodate the resident's medical needs, resulting in the resident not being readmitted within the required period.
Two residents requiring mechanical ventilation did not receive care according to professional standards when one resident's secondary ventilator alarm was left off after a shower, and another resident's primary ventilator alarm was set to low while the secondary alarm was out for repair. Both residents had significant cognitive and physical impairments, and staff interviews confirmed lapses in timely alarm management and communication.
Two residents in the facility had nasal cannulas that were not dated or labeled, contrary to the facility's policy requiring replacement every seven days. One resident with COPD and respiratory failure had a nasal cannula with potential dust accumulation, while another resident with similar conditions had condensation inside the cannula, posing a risk of bacterial growth. Additionally, the facility's laundry room contained opened beverage containers, potentially attracting pests.
A resident with dementia and other health issues was observed smoking unsupervised, contrary to their care plan requiring supervision. Additionally, a facility door and gate were left unlocked, posing a risk of residents leaving unsupervised. Staff acknowledged these lapses, which contravened the facility's safety policies.
The facility failed to provide appropriate IV care for two residents, leading to potential complications. One resident's IV dressing was not changed every 7 days, nor was the IV site changed every 72 hours as ordered. Another resident's IV site was not labeled with the date and time of insertion, hindering proper monitoring. These deficiencies were confirmed by staff and were against the facility's policies.
A facility failed to complete a POLST form for a resident with chronic conditions, leaving part D incomplete and unclear if an advance directive was in place. Despite the resident's capacity to make decisions, their cognition was moderately impaired, requiring assistance with daily activities. A nurse confirmed the oversight, highlighting the importance of documenting the resident's medical wishes.
The facility failed to maintain a comfortable sound level, as frequent alarm noise from an emergency door disturbed two residents. The alarm was triggered multiple times daily as staff used the door for transporting carts and retrieving shower chairs. Both residents, who have clear cognition and require moderate assistance, reported the noise as annoying, with one resident stating it sometimes disrupted their sleep. Staff acknowledged the issue, noting the potential for disturbance.
A resident with COPD, respiratory failure, and diabetes was observed smoking, but their MDS did not indicate tobacco use. The MDS Nurse confirmed the coding error, which could affect the resident's care plan, especially regarding safety while smoking and using oxygen.
A resident with chronic respiratory failure, major depressive disorder, bipolar disorder, and seizures did not have a comprehensive care plan in place, particularly for the use of hand mittens or restraints. Despite the resident's severely impaired cognition and need for dependent assistance, the facility staff, including an LVN and RN, confirmed the absence of a necessary care plan, which was acknowledged by the DON. This oversight contravened the facility's policies on care plans and restraint use.
A resident with COPD, respiratory failure, and diabetes was observed smoking without protective gear, despite a care plan requiring it. The care plan was not updated to reflect the resident's refusal to wear protective gear, posing a risk of burns. The facility's policy mandates ongoing assessments and revisions, which were not followed.
A resident with conditions complicating wound healing was observed without heel protectors while in bed, contrary to physician orders. The resident's MDS indicated a risk of pressure injury, and the facility's policy on pressure relief was not followed, potentially leading to pressure sores.
A resident with multiple health issues, including a risk for pressure injuries, was not provided with heel protectors as ordered by the physician while in bed. Observations revealed the absence of heel protectors, and an LVN confirmed the oversight, highlighting a failure to adhere to physician orders for skin management.
A facility failed to ensure proper storage and labeling of medications, as a bottle of Pro-Stat was found with sticky spillage in a medication cart. An LVN acknowledged that staff should clean such spills to prevent cross contamination. The facility's policy requires nursing staff to maintain clean and sanitary storage areas.
A resident with a history of seizures did not receive a scheduled Depakote level test as ordered by the physician. The test, intended to monitor the drug level and adjust dosing, was missed on the scheduled date, potentially affecting the resident's treatment. The facility's policy required such tests to be arranged and monitored by staff.
A facility failed to document the insertion and removal of IV lines for a resident with sepsis, as required by their policy. The resident's medical records lacked details on when and by whom the IV lines were placed or removed, despite the resident being prescribed IV-administered antibiotics. This deficiency was confirmed during a review of the resident's records and an interview with an RN.
The facility did not meet the required minimum living space of 80 square feet per resident in several shared rooms, each measuring only 235 square feet for three beds. This was confirmed through documentation review and observation. The Administrator noted potential negative impacts on residents' psychosocial well-being, safety, and comfort.
A resident with dementia and hemiplegia was observed wearing an ankle-foot orthotic device without a physician's order. Facility staff confirmed the device was necessary for maintaining a neutral ankle position, but the resident's care plan did not include the device, contrary to facility policy. This oversight risked inappropriate care and potential complications.
A resident with a fractured right index finger did not receive the prescribed buddy strap for nine days, as indicated by blank spaces in the Treatment Administration Record. Interviews with staff confirmed the oversight, which could delay healing. The responsibility for applying and documenting the buddy strap fell on the treatment nurse and LVNs, as outlined in their job descriptions.
A resident with a history of unauthorized departures and complex medical conditions was not adequately supervised, leading to multiple instances of elopement. The facility failed to activate exit door alarms, and the resident's elopement risk was not accurately assessed. Despite having a care plan requiring monitoring, staff did not implement necessary interventions, resulting in a deficiency in providing a safe environment.
A resident with cellulitis in both lower limbs did not receive wound care as ordered, and weekly assessments were not documented. The resident refused treatment once, and there was no follow-up documentation. A nurse later found maggots on the gauze, highlighting a severe lapse in care.
A facility failed to install alarms on all exit doors, resulting in a high-risk resident with severe cognitive impairment leaving undetected. Staff did not hear any alarms, and the front door, the only entrance and exit, lacked an alarm. The facility's policy required audible alarms to prevent unsupervised exits.
The facility failed to ensure CNAs had the necessary competencies to document and monitor meal intake percentages for three residents, leading to incomplete records and increased risk of undernourishment. Despite specific dietary orders, meal intake was not consistently documented, especially when food was brought in by families.
Failure to Timely Report Resident Fracture as an Unusual Occurrence
Penalty
Summary
The deficiency involves the facility’s failure to follow its Unusual Occurrence policy requiring that events threatening a resident’s welfare, safety, or health be reported to the California Department of Public Health (CDPH) within 24 hours. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment, and dependence on staff for all ADLs, including transfers and mobility. The resident was transferred to a general acute care hospital for hypotension, desaturation, shortness of breath, fever, and further evaluation. A chest radiology report at the hospital identified a subacute displaced fracture of the surgical neck of the right humerus. The facility’s Unusual Occurrence policy, dated 3/2010, required reporting such events to CDPH within 24 hours. The sequence of events shows that the family member learned of the right shoulder fracture from the hospital x‑ray results and then informed the DON two days after the hospital transfer. The DON and DOR reported being surprised by the fracture and indicated there had been no staff reports of falls or injuries involving the resident. The GACH social worker stated she had called the facility the day after the hospital transfer and informed a facility representative of the right shoulder fracture. Despite this information, the DON acknowledged that the facility did not report the fracture to CDPH because they did not know what had happened, even though the ADM stated that unusual occurrences were required to be reported so CDPH could determine through investigation whether the event constituted an unusual occurrence. This failure to report the fracture as an unusual occurrence within the required timeframe constituted the cited deficiency.
Failure to Assess and Investigate Resident’s Right Arm Pain and Shoulder Fracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and investigate a resident’s right arm pain and a subsequent right shoulder fracture. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side, severe cognitive impairment, and dependence on staff for ADLs. A CNA reported that during ADL care and dressing, the resident consistently reacted to movement of the right arm with moaning and saying “ouch,” and stated that charge nurses had been informed of this pain, though she could not recall specific dates or names. Another CNA stated that such complaints of right arm pain could indicate a possible fracture that staff were unaware of and needed to be assessed, addressed, and investigated. A family member observed that the resident had pain in the right arm when it was touched or moved and posted a note above the bed instructing staff to be mindful when caring for and repositioning the right arm because of the pain. An LVN acknowledged seeing this posted note, briefly touching the arm to check for swelling or redness, but did not further assess range of motion or pain with movement, did not contact the family member about the note, did not complete a change of condition assessment, and did not notify the physician. The DON later stated that the posted sign referred to the resident’s contracted right arm and that nurses were required to address concerns about the resident’s right arm pain, with charge nurses responsible for completing change of condition documentation and RNs to assess and notify the physician as needed. The resident was transferred to an acute hospital for hypotension and elevated pulse, and a chest x-ray performed there revealed a subacute displaced fracture of the surgical neck of the right humerus. The family member reported returning to the facility two days later to ask how the fracture occurred and was told by the DOR and DON that the facility was unaware of it and had no reports of falls or injuries. The DON stated that when she became aware of the fracture, she conducted only a verbal investigation with nurses and could not provide evidence of a written investigation, despite facility policy requiring prompt initiation and documentation of incident investigations and completion of an incident report within 24 hours. These actions and inactions resulted in the resident’s right arm pain not being timely assessed, the physician not being notified, and interventions to manage and treat the pain not being provided.
Failure to Develop Resident-Centered Care Plan for Pain, Mobility, and ADLs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan addressing pain management, mobility deficits, and ADL care for a resident with significant functional and cognitive impairments. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, musculoskeletal symptoms, and neurologic symptoms such as motor dysfunction. A History and Physical documented that the resident lacked capacity to understand and make decisions, and an MDS assessment showed severe cognitive impairment and dependence on staff for multiple ADLs, including dressing, toileting, transfers, mobility, oral hygiene, bathing, and dressing tasks. Therapy documentation further identified extensive functional limitations. A PT progress note indicated the resident required maximal assistance for bed mobility and sitting balance, with a need for upper extremity support. An OT progress note documented poor sitting balance during ADLs, also requiring maximal assistance and upper extremity support. Despite these findings, review of the resident’s care plans showed there were no care plans developed for pain management, mobility deficits, or ADL care, even though the facility’s policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet physical, psychosocial, and functional needs. Staff interviews confirmed ongoing pain complaints and the absence of appropriate care planning. CNAs reported that during ADL care, particularly when putting on the resident’s shirt or moving the right arm, the resident would moan, say “ouch,” and complain of pain, and that charge nurses had been informed, though dates and names could not be recalled. A family member stated they observed the resident having pain when the right arm was touched or moved and had posted a note above the bed reminding staff to be mindful of the painful, weaker side. Another CNA stated the resident’s complaints of right arm pain with movement could indicate a possible fracture needing assessment. The MDS nurse and DON both acknowledged that there were no care plans for mobility, ADLs, or pain, and stated that such care plans should have been developed and that nurses were responsible for creating and using these plans to guide care.
Failure to Assess, Document, and Manage Ongoing Right Arm Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with its own pain policy and professional standards for one resident with significant neurologic and musculoskeletal impairments. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side following a cerebral infarction, multiple joint contractures, severe cognitive impairment, and dependence on staff for all ADLs. Despite these conditions and the facility’s written Pain Assessment and Management policy requiring staff to assess for pain, recognize its presence, identify characteristics, address underlying causes, and develop and monitor pain interventions, staff did not consistently assess, document, or act upon ongoing signs and reports of right arm pain. Multiple CNAs reported that whenever they provided ADL care, including dressing and putting on the resident’s shirt, the resident would complain of right arm pain, moan, say “ouch,” or otherwise show signs of pain when the right arm was moved or touched. CNAs stated they informed various charge nurses/LVNs of the pain but could not recall specific names or dates, and they did not complete Stop and Watch forms to document these changes in condition as required. One CNA believed the pain complaints were “normal” due to the contracture and did not recognize the need for further assessment, while another CNA acknowledged that such pain could indicate a serious underlying issue. A nurse (LVN 1) reported observing facial grimacing during repositioning but did not document this as a change in condition because there were “no observed changes” in the resident’s pain. A family member posted a written note above the resident’s bed instructing staff to be mindful when touching, moving, or repositioning the resident’s right arm because of pain. LVN 2 acknowledged seeing this note but did not move or extend the arm to assess for pain, did not contact the family member to clarify the concern, did not notify the physician, and did not complete a change of condition report. The DON stated that charge nurses were responsible for completing change of condition reports when CNAs reported pain and that RNs were to assess the arm and notify the physician, but this process was not carried out. As a result of these failures to assess, document, and report the resident’s ongoing right arm pain and the posted family instruction, there was a delay in assessment, physician notification, and pain management interventions. The resident was later sent to a hospital for a change in condition, where imaging revealed a right shoulder fracture.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure CNAs implemented Enhanced Barrier Precautions (EBP) as required when providing activities of daily living (ADL) care to two residents on EBP. For Resident 2, surveyors observed an isolation cart and an EBP sign posted at the room entrance, but CNA 1 entered the room without donning an isolation gown and proceeded to assist the resident with ADL care. Resident 2’s records showed diagnoses of chronic respiratory failure, COPD, and ventilator dependence, with documentation that the resident lacked decision-making capacity and had severe cognitive impairment. The MDS indicated the resident was dependent on staff for ADLs, and the care plan for altered bladder elimination due to incontinence directed staff to implement EBP. For Resident 3, surveyors observed an isolation cart and an EBP sign at the room entrance, yet CNA 2 was in the room providing ADL care without wearing an isolation gown. Resident 3’s records documented chronic respiratory failure, Parkinson disease, and ventilator dependence, with an H&P indicating the resident lacked capacity to understand and make decisions and an MDS showing severe cognitive impairment and dependence for ADLs. Physician orders specified EBP related to the resident’s gastrostomy tube and tracheostomy, including applying EBP to prevent spread of infection during specific care activities such as toileting and changing incontinent briefs, and the care plan for bowel and bladder incontinence also directed implementation of EBP. During interviews, CNA 1 and CNA 2 each acknowledged that the posted EBP sign meant a gown should be worn for infection control, and an LVN confirmed that EBP includes donning gown and gloves before high-contact resident care. The facility’s EBP policy required staff to don gowns and gloves before performing high-contact resident activities such as bathing, providing hygiene, changing briefs, or assisting with toileting.
Inaccurate and Incomplete Documentation of Respiratory Status and Change in Condition
Penalty
Summary
The deficiency involves failures in accurate and complete documentation of a resident’s respiratory status and change in condition. The resident was admitted with acute and chronic respiratory failure, pneumonia, a tracheostomy, and ventilator dependence, and had documented moderate cognitive impairment and dependence on staff for most activities of daily living. The resident’s History and Physical noted coarse breath sounds, and the facility’s policies on Charting and Documentation and Change in a Resident’s Condition or Status required that all services, assessments, and changes in condition be documented objectively, completely, and accurately in the medical record. On the date of the incident, the Licensed Nurse Record for the resident showed a blank section where the breath sound assessment should have been documented. During interview, the LVN assigned to the resident stated that he had assessed the resident’s breath sounds but did not document his findings in either the Licensed Nurse Record or the Progress Notes, leaving the breath sound section blank. He acknowledged that, per facility policy, all observations and services provided, including breath sound assessments, should have been documented to facilitate communication among the care team and that inaccurate documentation prevents the team from knowing the resident’s condition. The resident’s Progress Notes and Change of Condition (COC) form for the same date contained conflicting times for the onset of respiratory distress and unresponsiveness. The Progress Notes, written by a respiratory therapist, indicated that the resident experienced respiratory distress and required emergency transport at 4:15 p.m., while the COC indicated the resident was found unresponsive and pulseless at 4:23 p.m., and the paramedic run sheet showed dispatch at 4:26 p.m. The Respiratory Manager stated that the respiratory therapist likely wrote the Progress Note later in the evening but inaccurately timed it as 4:15 p.m. instead of the actual time it was written, and the DON confirmed that the records were confusing and unclear, with the Progress Note time being inaccurate. These discrepancies and omissions resulted in an inaccurate and incomplete medical record for the resident.
Failure to Follow Out-on-Pass Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to follow its own policy and procedure regarding residents going out on pass (OOP) for three sampled residents. Specifically, OOP orders for these residents did not indicate whether the residents could leave unaccompanied by a responsible person or specify the length of time they were permitted to be out. For example, one resident with moderate cognitive impairment and physical assistance needs had an OOP order that did not clarify if accompaniment was required or the duration of the pass. Another resident's OOP order allowed them to go out with a family member but did not specify the length of time for the pass. A third resident's OOP order also lacked information on accompaniment and duration. Additionally, the facility did not ensure that residents were assessed before and after going out on pass, as required by policy. For one resident, there was no documentation of an assessment to determine stability prior to leaving or upon return. Staff interviews confirmed that assessments should be conducted to establish a baseline and ensure safety, but these steps were not documented or performed as required. The Director of Nursing acknowledged that the facility's policy was not followed, noting that OOP orders were missing critical information such as accompaniment requirements and duration, and that assessments before and after OOP were not documented. The facility's policy clearly states that in the absence of a specific order allowing unaccompanied leave, a responsible person must accompany the resident, and that licensed nurses must assess and document the resident's condition before and after OOP. These procedures were not adhered to for the residents in question.
Failure to Provide Required Written Notices for Bed-Hold and Transfer/Discharge
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the provision of written notices for bed-hold and transfer/discharge to residents or their representatives upon transfer to a general acute care hospital. Specifically, three residents with significant cognitive and physical impairments were transferred to hospitals, but neither they nor their responsible parties received the required written notifications about bed-hold options or transfer/discharge, as mandated by facility policy. The Director of Nursing (DON) confirmed during interviews that there was no process in place to generate and deliver these written notices within the required timeframe. For one resident with a history of tracheostomy, gastrostomy, hemiplegia, and major depressive disorder, the records showed she was dependent for most activities of daily living and unable to make medical decisions. Although a bed-hold was ordered and a family member requested it, there was no documentation that a written notice of bed-hold or transfer/discharge was provided to the resident or her representative. The family member also confirmed not receiving any written notification or information about the resident's rights or room change at the time of transfer. Two additional residents, one with severe dementia and another with tracheostomy, gastrostomy, and ventilator dependence, were also transferred to hospitals without receiving the required written notices. Both residents had significant cognitive impairments and required substantial or total assistance with daily activities. The DON acknowledged that the facility's policies on bed-hold and transfer/discharge documentation were not followed for these residents, and that the lack of written notification resulted in the residents and their representatives not being informed of their rights.
Failure to Hold Appropriate Bed for Resident with Tracheostomy During Hospital Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding bed-holds and resident returns when a resident with complex medical needs, including a tracheostomy, was transferred to a general acute care hospital for a planned cardiology clearance. The resident, who was dependent for all activities of daily living and unable to make medical decisions or communicate, had a responsible party who requested a 7-day bed-hold at the time of transfer. Documentation confirmed that the resident and family were informed of the right to a 7-day bed-hold, and a physician's order for the bed-hold was in place. Despite these measures, the facility did not hold the resident's original sub-acute bed, which was equipped to meet the resident's specialized care needs. Instead, the facility transferred the bed-hold to a room in the skilled nursing unit that was not equipped for residents with tracheostomies. The daily census records showed the resident's name was moved from the sub-acute unit to the skilled nursing unit during the bed-hold period, and the sub-acute bed was not kept vacant for the resident's potential return. Interviews with facility staff, including the DON, confirmed that the bed-hold was not appropriately maintained in the sub-acute unit, and the new room assignment could not accommodate the resident's medical requirements. As a result, the resident was not readmitted to the facility within the 7-day bed-hold period, contrary to facility policy and the resident's rights as outlined in the bed-hold notification and informed consent documentation.
Failure to Ensure Proper Ventilator Alarm Function and Settings for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required mechanical ventilation. For one resident with anoxic brain damage, tracheostomy, and respiratory failure, the secondary ventilator alarm located outside the room was observed to be turned off for approximately 25 minutes after the resident returned from a shower. The respiratory therapist responsible for the resident stated that the alarm was turned off during the shower and was not turned back on in a timely manner upon the resident's return. The resident was cognitively impaired and totally dependent on staff for activities of daily living, including respiratory care. For another resident with chronic respiratory failure, COPD, and dependence on a ventilator, the secondary ventilator alarm outside the room was not present because it was broken and had been sent to maintenance for repair. Additionally, the primary ventilator alarm at the bedside was set to a low volume, making it difficult for both the resident and staff to hear when the room door was closed. The respiratory therapist confirmed that the alarm should have been set to medium or high and acknowledged the increased risk due to the absence of the secondary alarm and the low setting of the primary alarm. The resident had moderate cognitive impairment and required substantial to maximal assistance with daily activities. Interviews with staff revealed a lack of timely communication and follow-up regarding the repair and reinstallation of the ventilator alarm. The maintenance supervisor was not informed about the broken alarm until he discovered it in his office, and the director of nursing confirmed that both primary and secondary ventilator alarms should be operational and set to high volume to ensure prompt care. Facility policies required immediate response to ventilator alarms and corrective action within the scope of practice, but these procedures were not followed in the cases observed.
Infection Control Deficiencies in Nasal Cannula Management
Penalty
Summary
The facility failed to ensure that nasal cannulas for two residents, identified as Resident 67 and Resident 147, were properly dated and labeled. This oversight was observed during inspections in the residents' rooms, where the nasal cannulas were attached to oxygen tanks but lacked any indication of when they were last replaced. The facility's policy requires oxygen tubing to be replaced every seven days, but the absence of dating and labeling made it impossible to verify compliance with this policy. Licensed Vocational Nurse (LVN) 3 confirmed the lack of labeling and acknowledged the risk of infection due to potential dust or dirt accumulation. Resident 67, who has chronic obstructive pulmonary disease (COPD), respiratory failure, and diabetes mellitus, was found with a nasal cannula that was not dated or labeled. The resident's cognitive abilities were moderately impaired, requiring moderate assistance for personal care and oxygen therapy. LVN 3 noted that the undated nasal cannula could lead to respiratory infections due to inhalation of dust or dirt. Resident 147, diagnosed with COPD, respiratory failure, and pneumonia, also had a nasal cannula that was not dated or labeled. This resident's cognitive abilities were severely impaired, making them dependent on staff for personal care and oxygen therapy. LVN 3 observed condensation inside the nasal cannula, which could harbor bacteria and increase the risk of respiratory infection. Additionally, the facility failed to maintain cleanliness in the laundry room, where opened and emptied beverage containers were found, potentially attracting pests.
Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who required supervision while smoking. Resident 9, who has diagnoses including hypertension, dementia, and congestive heart failure, was observed smoking unsupervised on the facility's smoking patio. The resident's care plan and smoking safety evaluation indicated that supervision was necessary during designated smoking times. However, during an observation, the resident was seen smoking without staff supervision, as the assigned Activity Assistant was on a break and not present to monitor the resident. This lack of supervision could have resulted in the resident injuring themselves while smoking. Additionally, the facility did not adequately monitor entrance and exit doors to prevent residents from leaving the premises unattended. An observation revealed that a door and an outside gate, which should have been locked, were left unlocked, allowing potential unsupervised egress. Staff interviews confirmed that the door was kept unlocked for staff convenience, despite a notice indicating it should remain locked. The unlocked gate was also acknowledged as a safety concern, as it could allow residents to leave the facility and potentially sustain injuries. The facility's policy emphasized the importance of maintaining a safe environment free from accident hazards, yet these practices were not adhered to, posing a risk to resident safety.
Failure to Provide Appropriate IV Care
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) care for two residents, leading to potential complications. For one resident, the facility did not change the IV dressing every 7 days and did not change the IV site every 72 hours as ordered. This resident was readmitted with diagnoses including sepsis and a urinary tract infection and was prescribed Zosyn to be administered via IV. Despite the order to change the IV site every 72 hours, documentation showed that the IV site was not changed, and the dressing was not replaced every 7 days, as confirmed by a registered nurse. The facility's policy required transparent dressings to be changed with each site rotation or at least every 7 days. For another resident, the facility failed to label the IV site with the date and time of insertion. This resident had diagnoses including hypertension, dementia, and diabetes and required substantial assistance with daily activities. During an observation, it was noted that the IV dressing lacked an insertion date and time, which is necessary for monitoring and timely changing of the IV to prevent infection. The facility's policy stated that nurses should write the date, time, and initials on the dressing label after IV insertion.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) form was completed for one of the sampled residents, identified as Resident 69. This oversight was discovered during a review of the resident's records, which showed that part D of the POLST form was incomplete. The resident, who had been admitted and readmitted to the facility, had a medical history that included chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus. Despite having the capacity to understand and make decisions as indicated in the resident's History and Physical, the Minimum Data Set assessment noted that the resident's cognition was moderately impaired, requiring partial assistance for daily activities. During an interview with a registered nurse, it was confirmed that the POLST form was incomplete, and it was unclear whether the resident had an advance directive. The nurse acknowledged that it was the responsibility of all nurses to ensure the POLST was filled out and emphasized the importance of completing part D to understand the resident's medical wishes in the event of a change in condition. The facility's policy on advance directives stated that residents have the right to formulate such directives, and information regarding their existence should be clearly documented in the medical record.
Frequent Alarm Noise Disturbs Residents
Penalty
Summary
The facility failed to ensure a comfortable sound level for residents, specifically affecting two residents, Resident 33 and Resident 56. The deficiency was observed when staff frequently set off an alarm while exiting the emergency door, causing disturbances throughout the day and night. Resident 33, who has clear cognition and requires moderate assistance for activities of daily living, reported that the alarm was constantly going off, causing annoyance and sometimes waking them up. Similarly, Resident 56, who also has clear cognition and requires moderate assistance, expressed that the alarm noise was very annoying. Observations and interviews revealed that the alarm was triggered multiple times as staff used the door to transport carts and retrieve shower chairs, with the alarm sounding at various times throughout the day. Licensed Vocational Nurse 1 and the Director of Nursing acknowledged the frequent alarm noise, noting that it was annoying and could potentially disturb residents' rest. The facility's policy on providing a homelike environment emphasizes maintaining comfortable noise levels, which was not adhered to in this instance.
Inaccurate Assessment of Resident's Smoking Habits
Penalty
Summary
The facility failed to accurately assess a resident for smoking, which led to a deficiency in the resident's care plan. The resident, who was diagnosed with chronic obstructive pulmonary disease (COPD), respiratory failure, and diabetes mellitus, was observed smoking on the patio. However, the Minimum Data Set (MDS) for the resident did not indicate tobacco use, despite the resident's smoking behavior. This discrepancy was confirmed during an interview with the MDS Nurse, who acknowledged that the MDS was incorrectly coded and needed to be updated to reflect the resident's current tobacco use. The inaccurate assessment of the resident's smoking habits had the potential to impact the development and implementation of an individualized care plan, particularly concerning the resident's safety while smoking and using oxygen. The facility's policy and procedure on the Resident Assessment Instrument (RAI) emphasized the importance of accurate assessments to prevent harm and ensure compliance with care planning requirements. The MDS Nurse stated that the MDS is updated annually, quarterly, and can be modified, highlighting the need for accurate coding to prevent potential harm to the resident.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was formulated for a resident, identified as Resident 76, who was part of a sample of 19 residents. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 76 had multiple diagnoses, including chronic respiratory failure with hypoxia, major depressive disorder, bipolar disorder, and seizures, and was assessed to have severely impaired cognition, requiring dependent assistance for activities of daily living. Despite these needs, there was no care plan in place for the use of hand mittens or restraints, which are critical for the resident's care and safety. Interviews with the facility's Licensed Vocational Nurse (LVN) and Registered Nurse (RN) revealed that care plans are supposed to be initiated upon admission and updated with any change in the resident's condition. However, both the LVN and RN confirmed that a care plan for the use of hand mittens or restraints was not created for Resident 76. The Director of Nursing (DON) also acknowledged that care plans are necessary to meet the resident's needs and that the absence of such a plan could result in unmet needs. The facility's policies on care plans and restraint use emphasize the importance of developing comprehensive, person-centered care plans with measurable objectives, which were not adhered to in this case.
Failure to Revise Care Plan for Smoking Safety
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 69, had a revised care plan to include wearing protective gear while smoking. Resident 69, who has chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus, was observed smoking without protective gear on the patio. The resident's care plan, dated March 6, 2024, indicated the need for observation, constant supervision, and protective gear while smoking, but did not list wearing protective gear as an intervention. This oversight had the potential to place the resident at risk of burns. During a review, it was noted that Resident 69's cognition was moderately impaired, requiring partial assistance for personal care. Despite the care plan's requirements, the resident refused to wear the protective gear, which was identified as an apron to prevent burns. The Registered Nurse (RN) acknowledged that the care plan should have been revised to reflect the resident's refusal to comply with wearing protective gear. The facility's policy on care plans emphasized the need for ongoing assessments and revisions as resident conditions change, which was not adhered to in this case.
Failure to Provide Heel Protectors for Resident at Risk of Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 6, had heel protectors on while lying in bed, as required by the physician's orders. Resident 6 was admitted with diagnoses including metabolic encephalopathy, respiratory failure, and diabetes mellitus, which are conditions that can complicate wound healing. The resident's Minimum Data Set (MDS) indicated a risk of pressure injury and a dependency on staff for personal care. Despite these risks, observations on two separate occasions revealed that Resident 6 was not wearing heel protectors while in bed, and there were no heel protectors available in the resident's room. During an interview with a Licensed Vocational Nurse (LVN), it was confirmed that the heel protectors were intended to prevent pressure sores on the resident's heels by reducing friction and pressure. The facility's policy on Support Surface Guidelines, which aims to prevent skin breakdown and promote circulation, was not adhered to in this instance. This oversight had the potential to result in pressure sores for Resident 6, highlighting a failure in providing the necessary care and services as per the resident's care plan.
Failure to Follow Physician Orders for Skin Management
Penalty
Summary
The facility failed to ensure that staff followed physician orders for one of the sampled residents, identified as Resident 6. Resident 6 was admitted with diagnoses including metabolic encephalopathy, respiratory failure, and diabetes mellitus, and was at risk for pressure injuries. The physician's orders, dated December 26, 2023, specified that Resident 6 should wear heel protectors while in bed for skin management. However, during observations on February 18 and February 20, 2025, Resident 6 was found lying in bed without heel protectors. Licensed Vocational Nurse (LVN) 4 confirmed during an interview and record review that the physician's orders required heel protectors to be worn while Resident 6 was in bed. LVN 4 acknowledged the importance of following physician orders to prevent skin breakdown. The facility's policy and procedure on physician orders, dated January 2020, indicated that all physician orders should be reviewed for accuracy on a monthly basis. Despite this policy, the failure to adhere to the physician's orders for Resident 6's skin management was observed, indicating a lapse in following established procedures.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as evidenced by a bottle of Pro-Stat, a liquid protein supplement, found with a large amount of sticky spillage on the container and inside a medication drawer in medication cart #4. During an observation and interview with an LVN, it was noted that a plastic bag with another medication was stuck to the Pro-Stat bottle, and the LVN acknowledged that the staff are responsible for cleaning such spills to prevent cross contamination. The facility's policy and procedure on the storage of medications, dated April 2007, requires nursing staff to maintain storage and preparation areas in a clean and sanitary manner.
Failure to Conduct Scheduled Depakote Level Test
Penalty
Summary
The facility failed to ensure that a Depakote level test was completed for a resident as per the physician's order. The resident, who was admitted with diagnoses including hypertension, diabetes, and seizures, had a physician's order for a Depakote level to be checked on the first Monday of every month. However, the test was not conducted on the scheduled date of February 3, 2025, following the last test on January 6, 2025. This oversight was identified during a review of the resident's medical records and confirmed by a registered nurse, who acknowledged the missed test. The resident's care plan included the completion of lab work as ordered to monitor and manage recurrent seizures. The facility's policy required staff to arrange for necessary tests and for nurses to ensure these tests were conducted to monitor drug levels. The failure to perform the Depakote level test as ordered could potentially result in inappropriate dosing, which might lead to seizures if the drug level is too low or other negative outcomes if the level is too high.
Failure to Document IV Line Management
Penalty
Summary
The facility failed to ensure proper documentation related to the insertion and discontinuation of intravenous (IV) lines for a resident who was readmitted with sepsis and a urinary tract infection. The resident was prescribed Zosyn to be administered via IV every 8 hours for 10 days. However, the medical records lacked documentation of when and by whom the IV lines were inserted or removed. Specifically, there was no record of the IV line placement in the right hand on 9/9/2024, nor was there documentation of its removal. Additionally, there was a lack of documentation regarding the removal of an IV line from the left arm between 9/11/2024 at 7:08 a.m. and 9/11/2024 at 2:02 p.m. The facility's policy requires that all services provided to residents be documented in their medical records, including treatments or services performed. The absence of documentation regarding the IV lines for this resident indicates a failure to adhere to this policy. This deficiency was identified during a review of the resident's medical records and an interview with a registered nurse, who confirmed the lack of documentation and emphasized the importance of recording such information to communicate effectively with other nursing staff.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents in multiple rooms had the required minimum living space of 80 square feet per resident in shared rooms. Specifically, rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40, which each contained three beds, measured only 235 square feet, falling short of the required 240 square feet. This deficiency was identified through a review of the Client Accommodation Analysis and a Room Variance Waiver request letter, as well as direct observation by surveyors. During an interview, the Administrator acknowledged that the smaller room size could negatively impact residents' psychosocial well-being, safety, and comfort.
Failure to Obtain Physician's Order for Orthotic Device
Penalty
Summary
The facility failed to obtain a physician's order for an ankle-foot orthotic device for Resident 1 before its implementation. Resident 1, who has a history of dementia, osteoarthritis, and hemiplegia affecting the left side, was observed wearing the orthotic device without a corresponding physician's order. The lack of a physician's order for the device was confirmed during a review of Resident 1's active physician orders and care plans, which did not include any mention of the orthotic device. Interviews with facility staff, including an LVN and the Director of Rehabilitation, revealed that the orthotic device was used to maintain a neutral ankle position and prevent injury when Resident 1 was out of bed. However, the Director of Nursing confirmed that the facility's policy and procedure required care plans to describe all services provided to a resident, and Resident 1's care plan did not include the orthotic device. This oversight placed Resident 1 at risk of receiving inappropriate care, potentially leading to skin breakdown and joint complications.
Failure to Implement Physician's Order for Buddy Strap Application
Penalty
Summary
The facility failed to implement a physician's order for a resident to wear a buddy strap on their right index finger for nine days. The resident, who had a history of dementia, osteoarthritis, and hemiplegia affecting the left side, was admitted and readmitted to the facility. The physician's order, dated 1/20/2025, specified that the buddy strap should be worn during the day to aid in the healing of a fractured right index finger. However, a review of the Treatment Administration Record (TAR) from 1/21/2025 to 1/29/2025 showed blank spaces, indicating that the buddy strap was not applied during this period. Interviews with the Director of Rehabilitation and a Licensed Vocational Nurse (LVN) confirmed that the buddy strap was not applied, which could potentially delay the healing process. The Director of Nursing stated that the treatment nurse and LVNs were responsible for ensuring the application and documentation of the buddy strap. The job descriptions for the Treatment Nurse and Charge Nurse LVN, dated 2003, indicated their responsibilities in providing therapeutic services and coordinating nursing services to maintain a resident's treatment regimen.
Failure to Provide Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to provide a safe environment for a resident by not implementing adequate supervision and interventions. The resident, who had a history of leaving the facility without authorization, was not properly monitored despite having a care plan that required staff to monitor behavior symptoms such as wandering and inappropriate responses. The resident had a complex medical history, including encephalopathy, bipolar disorder, and major depressive disorder, which were not adequately considered in the elopement risk assessment. The facility's exit door alarms were not consistently activated, which contributed to the resident's ability to leave the facility unnoticed. On multiple occasions, the resident left the facility without signing out or having the necessary physician's order, despite staff attempts to prevent this. The facility's policy required door alarms to be on at all times, but staff failed to activate them after use, allowing the resident to exit without detection. The facility's elopement screening did not accurately assess the resident's risk, as it failed to account for the resident's diagnoses and history of unauthorized departures. The resident's care plan included interventions for monitoring and supervision, but these were not effectively implemented, leading to the resident's unsupervised departure. The facility's policies on safety and supervision were not followed, resulting in a deficiency in providing a safe environment for the resident.
Failure to Provide Wound Care and Weekly Assessments
Penalty
Summary
The facility failed to provide appropriate wound care and services for a resident admitted with cellulitis in both lower limbs. The resident had a physician's order to cleanse the lower extremities with Dakin's solution, apply Bactroban ointment, and cover with kerlix daily for seven days. However, on one occasion, the resident refused treatment, and there was no documentation indicating that the treatment was completed later. Additionally, the Treatment Administration Record showed that the wound treatment was marked as refused, and there was no evidence of the treatment being administered afterward. Furthermore, the facility did not conduct weekly assessments of the resident's wound as required. The Weekly Non-pressure Ulcer Observation Tool lacked documentation for two consecutive weeks. This oversight was compounded when a nurse discovered maggots on the gauze during a wound treatment, indicating a severe lapse in care. Interviews with staff revealed that the nurse did not complete the wound care on the day of refusal and failed to document the weekly wound progress, which is crucial for monitoring the resident's condition.
Failure to Install Exit Alarms Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that all doors leading to the outside were equipped with alarms, which resulted in a high-risk resident for elopement leaving the facility undetected. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was last seen in bed but was later found missing. Staff, including an LVN and RN, did not hear any alarms during their shifts, and the resident did not have any devices to notify staff if she left the facility. Interviews with staff revealed that there was no alarm installed on the front door, which was the only entrance and exit for staff, residents, and visitors. The Director of Nursing and Maintenance Personnel confirmed that the front door lacked an exit alarm, and as a result, there was no sound to alert staff if a resident left through it. The facility's policy on elopement indicated that exit doors should be safeguarded with audible alarms to alert staff when a resident attempts to leave unsupervised. This deficiency had the potential for the resident to be injured while outside the facility without supervision.
Failure to Document and Monitor Meal Intake Percentages
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) had the necessary competencies and skill sets to document and monitor meal intake percentages for three residents. Resident 1, who had diagnoses including hyperlipidemia, unspecified protein-calorie malnutrition, and iron deficiency anemia, refused meals multiple times over several months. Despite having orders for a regular diet with specific consistencies, the documentation showed numerous instances of meal refusal without proper follow-up or documentation of alternative food intake from outside sources. Resident 1's mental capacity was also noted to be impaired, complicating the situation further. Resident 2, diagnosed with hyperlipidemia, unspecified protein-calorie malnutrition, and dysphagia, had cognitive impairments and was dependent on assistance for activities of daily living (ADLs). The documentation for Resident 2 lacked meal intake percentages on specific dates, despite having orders for a regular diet with pureed texture and thin liquids. This lack of documentation was confirmed during interviews with staff, who acknowledged the importance of accurate meal intake records for nutritional assessment and intervention. Resident 3, with diagnoses including iron deficiency anemia, unspecified protein-calorie malnutrition, and dysphagia, also had cognitive impairments and was dependent on assistance for ADLs. Similar to Resident 2, the documentation for Resident 3 did not indicate meal intake percentages on specific dates, despite having orders for a controlled carbohydrate diet with mechanical soft texture and thin liquids. Interviews with CNAs and the Director of Nursing (DON) revealed that the staff were aware of the need to document food intake accurately, especially when food was brought in by families, but failed to do so consistently. This deficiency in documentation increased the risk of undernourishment for the residents involved.
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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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