Marquis Care At Shasta

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not protect a resident from physical abuse when a CNA was observed putting hands on the resident’s shoulders, firmly shaking the resident, and loudly telling the resident to stop. The resident had diagnoses of delusional disorder, dementia, and Alzheimer’s disease, was not their own responsible party, and had severely impaired cognitive skills with short- and long-term memory problems. The resident also required substantial to maximum assistance with dressing, transfers, and bed mobility, and was dependent on staff for toileting hygiene. The resident’s care plan for physical aggression and abusive behaviors directed staff to approach slowly, avoid invading personal space, ensure the resident’s attention before touching or speaking, and use a calm, low voice to reduce undesired behaviors. The resident had behaviors including screaming, threatening others, refusing care, and feeling anxious and agitated. During interview, another CNA stated the coworker was sometimes rough during care and described seeing the CNA grab the resident by the shoulders and shake the resident while telling the resident to stop loudly; the CNA then took over care and calmed the resident. The Administrator later acknowledged that the witnessed physical contact would be considered an allegation of abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report two allegations of physical abuse to CDPH, the local police department, or the Ombudsman’s office. Facility policy required allegations or suspicions of abuse to be reported immediately to the Administrator and then immediately or within two hours to CDPH, the police department, and the Local Ombudsman’s office. The deficiency involved two residents and centered on allegations that were not treated as reportable abuse events by facility leadership when they were brought to staff attention. One resident, who had a history of age-related osteoporosis and flaccid hemiplegia affecting the left side, was diagnosed with an unspecified fracture of the lower end of the left ulna after a hospital evaluation. The resident stated that two CNAs provided care in bed, turned the resident side-to-side, and during turning the resident’s left arm hit the bed cane and began hurting. The resident later told the RCM about the incident after returning from the hospital. The RCM confirmed that when the resident returned, the resident alleged the fracture occurred while receiving care from two CNAs, but the RCM did not consider it an allegation of abuse because the resident had not reported it on the day it occurred and there was no documentation of pain before hospitalization. The RCM did not notify the Admin until the morning of the following day. A second resident, who had diagnoses including delusional disorder, dementia, and Alzheimer’s disease, was the subject of a witnessed incident reported by CNA B. CNA B stated that while assisting CNA C with care, CNA C grabbed the resident by the shoulders, shook the resident, and told the resident to stop in a loud voice. CNA B said the resident had increased verbal and physical behaviors and that CNA C appeared overwhelmed, and CNA B took over the resident’s care and had CNA C leave. The Admin, DON, and Director of Staff Development confirmed that CNA B did not notify them of the abuse she witnessed, and the facility confirmed that neither the resident’s allegation nor the witnessed physical abuse was reported to CDPH, the local police department, or the Ombudsman’s office.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not thoroughly investigate an allegation of abuse involving a resident who reported that two CNAs provided rough care that caused injury. The facility’s Abuse Investigations policy required a thorough investigation of any abuse allegation, including interviewing possible witnesses such as staff, the resident’s roommate, and other residents cared for by the accused staff member. In this case, the resident had a long-term admission history, age-related osteoporosis, left-sided flaccid hemiplegia, and was dependent on staff for showers, toileting hygiene, and rolling in bed. The resident also had intact cognition with a BIMS score of 15 out of 15. The resident stated that during bed care, the CNAs turned the resident from side to side and the resident’s left arm hit the bed cane. The resident later went to the hospital for breathing difficulty and then focused on left arm pain, reporting to the hospital physician what had occurred during the care provided by the CNAs. Hospital records showed an x-ray with a minimally displaced distal ulnar shaft fracture of the left arm. When the resident returned to the facility, the RCM documented speaking with the resident about the wrist fracture and the resident again stated that the injury occurred when the resident was rolled in bed and the left hand hit the bed cane. The RCM confirmed that allegations of rough care or injury during care were treated as allegations of abuse and that Admin would be notified immediately. However, the RCM stated the allegation was not considered abuse because the resident did not report it until after the hospital stay and there was no documentation of pain before hospitalization. The RCM also confirmed that no possible witnesses were interviewed, including staff, the resident’s roommate, or other residents cared for by the accused CNAs. Admin confirmed the allegation was not thoroughly investigated and that staff or the resident’s roommate had not been interviewed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the dietary manager met the education qualification requirements outlined in California Health and Safety Code HSC 1265.4. During interview, the Dietary Manager stated he was responsible for managing the kitchen and acknowledged that his Certified Dietary Manager credential expired on 8/31/22. The Registered Dietitian Nutritionist also acknowledged that the dietary manager's credential had expired and stated that her role included nutrition assessments, monitoring weights, participating in weight committee meetings, monitoring pressure injuries, and completing monthly kitchen audits and tray line observations, with 4-6 hours per week spent overseeing the kitchen. A review of the Dietary Manager job description dated 9/5/23 and signed by the Dietary Manager stated that the education requirement for the position was Certified Dietary Manager. Review of the facility's documents for the dietary manager's qualifications did not show evidence that he met the requirements under HSC 1265.4. During the recertification survey, multiple kitchen issues were also observed, including floors and equipment that were not cleaned and dried properly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure menu recipes were followed during lunch meal preparation for both regular and pureed diets. During a kitchen observation, steamed zucchini was found on the counter without seasoning, and the cook stated he did not add seasoning and did not refer to a recipe while cooking. The facility policy stated that recipes would be followed for menu items, and the documented roasted zucchini method required oil and specific seasonings for the regular recipe. During preparation of pureed zucchini, the cook used two large scoops of cooked zucchini, added water and thickener, blended the mixture, and stated he did not measure ingredients and relied on sight. He also did not refer to a recipe during the pureed process. The facility’s documented pureed zucchini method required portions from the regular recipe to be processed in a food processor and thickener to be added in a specified amount for every five portions. The same cook prepared BBQ chicken for both regular and pureed diets without following the documented methods. For the pureed BBQ chicken, he blended cooked chicken with water and thickener without using the recipe, and the puree meal was observed running together on the plate at tray line. The pureed BBQ chicken also had a scoop of BBQ sauce on top, although the therapeutic spreadsheet did not include BBQ sauce for the puree diet. For the regular BBQ chicken, BBQ sauce was poured over cooked chicken at the end rather than being added and baked according to the recipe. The registered dietitian confirmed that recipes should be followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food safety and sanitation requirements were not followed in the kitchen when multiple areas and items were found unclean or improperly maintained. During observation, grease and grime were seen on the sides and doors of stoves, on top of the cooking range, and on the sidewalls and surfaces of the hot oil fryer. The exterior walls of a fridge at the food preparation station were also visibly coated in grease and dust. The Dietary Manager acknowledged the dirty condition of the fridge walls and stated they were dirty. Facility policy required refrigerator shelves, ceilings, and walls to be washed with warm water and detergent and cleaned per schedule, and the USDA Food Code requires non-food contact surfaces to be kept free of dust, food residue, and debris. Kitchen utensils and equipment were also found stored wet, including stainless steel blenders, metal food scoops, and plastic food storage tubs, with visible water drops present on some items. Staff acknowledged that these items should not be stored wet and should be dry, and facility policy required all items to be air-dried with no moisture remaining. In addition, two plastic cutting boards were observed to be deeply cut and scored, and the Dietary Manager stated they should not be used and should be replaced. The dry storage pantry floor was observed to be soiled with dark grime, food particles, and dust, especially along the edges of the room, and the Dietary Manager acknowledged the dirty condition and stated it could use scrubbing. Facility policy required the storeroom floor to be swept and mopped daily.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate discharge processes for two residents when they were transferred to the hospital and then not allowed to return to the facility. For both residents, the medical record did not contain documented physician reasons supporting the decision not to readmit them, and there was no evidence that either resident or their family member was prepared in advance for discharge from the facility or notified of the right to appeal the discharge decision. Resident 3 was admitted with diagnoses including metabolic encephalopathy, acute kidney failure, and adult failure to thrive. The most recent MDS showed severe cognitive impairment, and the resident was not his own representative but could verbalize simple wants and needs. Facility staff confirmed Resident 3 was sent to the hospital for IV placement and because of combative behavior toward staff during an IV attempt. The facility decided the next day not to take the resident back, faxed a Notice of Proposed Transfer and Discharge to the Ombudsman, and did not notify the resident’s family member. The record contained no documentation that Resident 3 had been aggressive, harmful, or dangerous toward other residents, and staff confirmed there was no physician documentation stating the resident’s needs could not be met by the facility or that he posed a danger to others. The resident’s family member stated they were told only about the hospital transfer and first learned the resident had not been accepted back from hospital case management. Resident 137 was admitted with diagnoses including dementia with behavioral disturbance, conduct disorder, and Alzheimer’s disease. The MDS showed moderately impaired cognition with poor decision-making and behaviors including hitting, scratching, threatening, and cursing at others. Facility staff confirmed they told hospital case management that the resident would not be accepted back and considered the resident discharged because staff and other residents were endangered by the resident’s presence. Staff described the resident as verbally and physically aggressive and stated the resident had attacked staff with fists, a butter knife, and a fork, but also confirmed no residents were attacked or threatened. The resident’s family member was not notified, the Notice of Proposed Transfer and Discharge form could not be located, and there was no evidence that the resident or family member were informed of the right to appeal the discharge decision.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food and drink were not consistently served at a palatable, attractive, or safe appetizing temperature for multiple residents. During interviews, several residents stated the food was cold, bland, tough, dry, or otherwise unappetizing, and one resident reported not knowing that alternatives could be requested. Another resident said breakfast arrived warm but not hot and that egg whites were cold, while others described repeated issues with cold pasta, limited choices, and watered-down milk. Five confidentially interviewed residents also reported that filled-out menus were not being returned to the kitchen, leaving only sandwiches as alternatives and contributing to meals that were often cold and not reheated for residents eating in their rooms. During a lunch tray observation, temperatures of hot and cold items were measured on regular and pureed diet trays. Hot items such as chicken and zucchini were recorded at 125 F and 148 F on the trays, while cold items such as potato salad were recorded at 48 F and 52 F. A concurrent review with the Dietary Manager showed the facility’s test tray evaluation records expected hot foods to be served between 135 F and 160 F, and those records also documented hot food temperatures of 122 F and 103 F and cold food at 58 F. The Dietary Manager acknowledged the tray temperatures were cooler than expected and had known about the issue since October 2025. The facility policy titled Food Temperature stated potentially hazardous cold foods should be no greater than 41 F or served according to state regulation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure glucose testing was performed in accordance with its infection control policies and procedures for three sampled residents. The facility policy for standard precautions required hand hygiene before and after glove use, and the policy for obtaining a fingerstick glucose level required hand hygiene before testing, clean gloves, and allowing alcohol used to clean the fingertip to dry completely before puncturing the skin. During observation, a licensed nurse put on gloves without washing hands before testing the blood sugar of two residents, wiped each resident’s fingertip with an alcohol wipe, and immediately punctured the fingertip before the alcohol was dry. During another observation, a licensed nurse put on gloves without washing hands before testing a resident’s blood sugar and then wiped the fingertip with an alcohol wipe and waved her hand over it to dry it. The nurse walked through the hallway with the same gloves on, disposed of bloody items at the medication cart, disinfected the glucometer, entered data into the resident’s electronic health record, removed the dirty gloves without washing hands, prepared the resident’s insulin pen, touched the medication cart, drawers, insulin pen, and packaged supplies, then applied gloves again without washing hands and administered insulin without washing hands or putting on clean gloves. The nurse later returned the insulin pen to the medication drawer while touching the cart, drawer, and computer keys before removing the dirty gloves. The DON stated nurses are expected to wash hands before putting on and after removing gloves and before doing a glucose test, and that alcohol should be allowed to air dry before using the lancet.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to appropriately monitor the specific symptoms for which psychoactive medications were prescribed for two sampled residents, Resident 11 and Resident 130, and did not ensure they were free from chemical restraints related to behavioral management medications that could cause excessive sleepiness. The facility policy titled, Psychoactive Medication Management and Chemical Restraint Prevention, indicated residents would be monitored when the physician prescribed psychoactive medications. However, during record review and interviews, staff confirmed that the behavior notes in use were generalized and did not track the residents’ targeted behaviors for the prescribed medications. Resident 11 was admitted with diagnoses of bipolar disorder, current mixed episode, severe, with psychotic features, and major depressive disorder, and was not their own responsible party. The physician prescribed olanzapine for severe mood swings, Rexulti for severe mood fluctuations and mania, Seroquel for delusions, hallucinations, and manic thoughts, and sertraline for sadness and tearfulness. The Resident Case Manager and DON confirmed there were no specific monitors in place for the targeted behaviors associated with these medications. Resident 130 was admitted with major depressive disorder, severe, with psychotic features, and was prescribed bupropion for self-isolation, refusal of care, and sadness, and quetiapine for hallucinations, paranoia, and delusions that caused fear. The Resident Case Manager stated behavior monitoring was done through alert charting when medications changed and charting by exception after four to six weeks, but confirmed there were no monitors tracking Resident 130’s targeted behaviors for bupropion and quetiapine. The Administrator also confirmed the behavior note was generalized and there was no monitor in place for either resident’s specific targeted behavior for psychotropic medication use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The comprehensive care plan was not reviewed and revised for two sampled residents after their assessments identified needs that were not reflected in the plan. Facility policy stated care planning begins on admission and is an interdisciplinary process involving nursing, social services, activities, and dietary staff. Surveyors found that the care plan for one resident with diagnoses including lumbar fracture, pacemaker, dysphagia, hypertension, dementia, anxiety, and depression did not include specific activity preferences such as watching channel 44 for favorite programs or having her room board updated with the date because of memory loss. That resident’s most recent MDS showed slight cognitive impairment with a BIMS score of 12 out of 15. During interview, the resident stated she felt overlooked and said she liked to watch a favorite Christian program but could not remember the channel. A roommate stated the resident loved to watch channel 44 and needed reminders so she could watch the programs she enjoyed. The RCM and AD confirmed the care plan should have been more resident specific and that reminders, daily date updates, and preferred activities such as religious pictures and puzzles should have been addressed in the care plan. Surveyors also found that another resident with diagnoses including depression, kidney neoplasm, obstructive and reflux uropathy, neuropathy of both legs, pneumonia, COPD, diabetes, sepsis, muscle weakness, and hypertension did not have specific nursing interventions for shaving himself with his electric razor or for refusals to get out of bed. His MDS showed slight cognitive impairment with a BIMS score of 13 out of 15. The resident stated he could shave himself if he had a mirror and wanted to shave every other day, but staff shaved him twice weekly. He also stated he would get out of bed if staff used the Apex lift instead of the Hoyer lift. A CNA confirmed she shaved him twice weekly, did not know he had an electric razor, and said he often refused to get up. The RCM confirmed the care plan needed multiple revisions and that staff needed to document refusals and encourage him to get out of bed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a telephone order for Artificial Tears was correctly transcribed for one resident with dementia, bladder and intestine infections, and dry, irritated eyes. During observation, the resident was administered Artificial Tears eye drops to both eyes, and the resident had redness and swelling to both lower eyelids. However, the Medication Administration Record listed the order as Artificial Tears to be instilled in both ears instead of both eyes, including both the routine and as-needed directions for dry, irritated eyes. Record review and staff interviews showed that a licensed nurse transcribed the telephone order on 7/8/25 with the wrong route of administration. The physician electronically signed the order and later reviewed it multiple times without recognizing that it had been entered for the ears rather than the eyes. Monthly order reviews by nursing, the physician, and the pharmacy consultant also did not identify the error, and the pharmacy consultant later stated the directions should have been for the eyes, not the ears.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Expired medications and treatment supplies were found on the Transitional Care Unit treatment cart during an observation and concurrent interview with the Treatment Nurse. The cart contained one tube of Coloplast Hydrophilic wound dressing gel with an expiration date of 7/31/25, one tube of Benadryl cream that expired in 6/2025, five hemorrhoid suppositories that expired in 9/2025, and fifteen Bisacodyl 10 mg suppositories that expired in 6/2025. The Treatment Nurse confirmed the items were expired and should not have been available for resident use. Record review showed the facility policy required nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner, and the pharmacy policy stated expired medications were to be removed from active supply and destroyed. During interview, the Treatment Nurse stated he was not aware of who was responsible for checking and removing expired treatment supplies and medications from the treatment cart. The DON stated the Infection Control Nurse and Resident Care Managers were responsible for checking carts monthly, and nursing staff were responsible for checking daily, but she was unaware the expired items were on the TCU treatment cart.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that one sampled resident’s minced and moist (MM5) therapeutic diet was prepared according to the recipe. During a kitchen observation, the cook was preparing minced and moist chicken without referring to the recipe, and later a MM5 tray for the resident included minced chicken with BBQ sauce on top. The facility’s BBQ Chicken Method stated that MM5 chicken should be deboned, minced from regular cooked portions, and served with thick gravy. The Dietary Manager reviewed the tray and stated that it did not meet IDDSI guidelines for texture and was not following the resident’s MM5 diet order. The facility also failed to maintain a current and complete diet manual reference for nursing staff. A nurse at the nursing station could not locate the diet manual and stated she had never heard of it or knew what it was used for, prompting the RDN to bring the manual from another nursing station. Review of the facility diet manual showed it did not include information on the soft and bite sized (SB6) and minced and moist (MM5) diets, even though the diet spreadsheet listed both diets. The Dietary Manager stated the manual approved on 1/30/26 did not include puree, SB6, or MM5 information and acknowledged that the mechanically altered diet information for IDDSI should be included so nurses would have a reference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a Certified Nursing Assistant (CNA) failed to treat a resident with respect and dignity during direct personal care. The resident, who had severe cognitive impairment and multiple complex diagnoses including Alzheimer's disease, vascular dementia with agitation, delusional disorder, and other significant medical conditions, became agitated and combative during a linen change. During this episode, the CNA held the resident's hands down on his chest to prevent him from hitting staff, despite being told multiple times by another staff member to stop. The facility's policy requires that all residents, including those with cognitive impairments, be treated with dignity and sensitivity, and that staff address the root causes of behaviors rather than physically restraining or contradicting residents. The incident was witnessed by another CNA, who intervened and reported the misconduct immediately. Interviews with facility leadership and staff confirmed that the resident's rights and dignity were violated during the incident, and that holding a resident's hands or restraining them in this manner is unacceptable. The resident's medical record indicated a need for maximum assistance with personal care and a history of combative behaviors, but staff are expected to respond appropriately without compromising the resident's dignity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely responses to residents' requests for assistance, specifically for one resident who experienced significant delays in call light responses. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, yet this was not upheld as evidenced by the delayed response times. During an interview, the resident expressed feelings of unfair treatment due to the frequent long waits for assistance, which were documented in the call light logs. The resident, who was admitted with multiple diagnoses including depression, diabetes, and chronic obstructive pulmonary disease, was capable of making her own decisions as indicated by her BIMS score. Despite this, the call light logs revealed 54 instances where the response time exceeded 20 minutes, with the longest wait time being one hour on several occasions. The Director of Staff Development acknowledged that staff are expected to answer call lights promptly, yet the logs indicated a pattern of delayed responses, contributing to the resident's feelings of neglect.

Plan Of Correction

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 call lights will be responded to timely. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All residents could be affected by this practice. Facility QA committee to meet to review call light logs for any patterns/units/shifts where longer call light times may be occurring and conduct a Root Cause Analysis for overall improvement in meeting timely call light times. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? DSD inserviced all staff on answering call lights in a timely manner. Including turning off call light when responding to needs, reactivating call light if more assistance is required by resident. Often call lights are forgotten to be deactivated until after all cares are delivered. How the facility plans to monitor its performance to make sure that the solutions are sustained. DSD will run call light report to ensure lights are being answered in a timely manner weekly x4 weeks, then monthly x90 days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise the care plan for a resident who experienced a significant unintentional weight loss of 5% in one month. The resident, who was admitted with multiple diagnoses including depression, adult failure to thrive, diabetes, and COPD, expressed a desire to regain weight. Despite the facility's policy requiring re-weighing and dietitian consultation for significant weight changes, the resident's care plan was not updated to address the weight loss. Interviews and record reviews revealed that the resident consumed 25% or less of meals 63 times out of 86 meals monitored over a month. The Registered Dietitian acknowledged the significant weight loss but had not discussed it with the resident or revised the care plan. The Resident Care Manager noted that the resident refused to be re-weighed, and the facility's protocol did not account for such refusals. The facility Administrator confirmed that the care plan should have been updated to reflect the resident's weight loss.

Plan Of Correction

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 4's care plan was corrected to reflect the significant weight loss of 5% in one month. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All other residents with significant weight loss have the potential to be affected. RD will conduct 100% audit of all residents with significant weight loss to ensure interventions and/or revisions are reflected in the care plan. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? Resident Care Managers, RD, and LN were inserviced by DNS to ensure care plan is to be updated with significant weight loss. How the facility plans to monitor its performance to make sure that the solutions are sustained. RCMs will check each care plan to ensure significant weight loss is present if indicated weekly x4 weeks, then monthly x90 days. Results will be reviewed by QA Committee. Date corrective action will be completed: 4/3/2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nurses demonstrated appropriate competencies in assessing and documenting the condition of a surgical site for a resident. Despite the facility's policy requiring documentation of wound assessments, two licensed nurses did not document the presence of a surgical incision in the resident's progress notes. This oversight led to a delay in identifying an infection at the surgical site, which was later found to be inflamed and draining purulent material, necessitating antibiotic treatment. Additionally, a certified nurse assistant incorrectly documented that a resident received a shower, although the resident reported not having received one since admission. This discrepancy was confirmed by the CNA, who admitted to mistakenly documenting the shower. The resident expressed frustration over not receiving proper hygiene care, which was corroborated by the facility's documentation schedule. The facility also failed to address long call light wait times experienced by multiple residents, with documented instances of wait times exceeding 30 minutes. Residents reported waiting for assistance with basic needs, such as using the bathroom, which led to discomfort and distress. The facility's policy required prompt response to call lights, but the electronic time logs confirmed prolonged wait times. Furthermore, the competency checklists for registry staff relied on self-assessment without external validation, raising concerns about the adequacy of staff competencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pureed food recipes were followed, resulting in unappetizing food that potentially did not meet the nutritional needs of 11 residents on pureed diets. Observations revealed that the staff did not adhere to the specified quantities and procedures outlined in the recipes for various pureed foods, including spinach, cornbread, sweet potatoes, and roast turkey. For instance, the staff used incorrect amounts of ingredients and did not measure liquids accurately, which deviated from the recipes' instructions. During interviews, the Registered Dietitian confirmed that recipes should be followed exactly and cannot be altered without approval. The facility's policy also indicated that recipes must be adhered to for menu items. The failure to follow these recipes as prescribed could lead to the residents receiving diets that do not meet their nutritional needs, as the food prepared was not in accordance with the dietary guidelines set by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the food provided to residents was appetizing, palatable, and served at a safe and appetizing temperature. Observations and interviews revealed that 14 out of 115 residents expressed dissatisfaction with the quality of the food. Specific complaints included food not being to the residents' taste, meals not being warm, and the quality of the food being poor. Residents reported issues such as hard meat, spoiled fruit, overcooked vegetables, and incorrect meal orders. Several residents, including those with intact cognition and those with cognitive impairments, voiced their dissatisfaction during interviews. For instance, one resident mentioned that the food was not to their taste, while another stated that the food was not always warm and not very good. Another resident reported that the meat was very hard, and the vegetables were overcooked. Additionally, some residents noted that they did not receive the meals they ordered, and items were often missing from their trays. The Registered Dietician confirmed that one resident had experienced weight loss, and a Nutritional at Risk Assessment had not been completed. The Certified Dietary Manager stated that they had a good relationship with the residents and conducted monthly food satisfaction surveys. However, the dissatisfaction expressed by the residents indicates a failure in the facility's food service, potentially impacting the residents' nutritional intake and overall satisfaction with their meals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor the food preferences of seven residents, leading to dissatisfaction with meals and potential nutritional issues. Resident 577, who was cognitively intact, reported not receiving the meals ordered and receiving food items like ham, which they disliked. This resident also expressed difficulty eating hard meat, which was necessary for protein intake to aid in healing foot wounds. Resident 61, who had multiple fractures, selected a pork chop but received a different meal, which she did not eat due to its spiciness. The Certified Dietary Manager could not explain the discrepancy in meal orders. Resident 579, who was severely cognitively impaired, also reported not receiving the meals ordered. Resident 580, who was cognitively intact, experienced issues with unavailable food items and cold meals. Resident 69, with moderate cognitive impairment, and her daughter noted frequent meal substitutions, particularly on Sundays. The daughter expressed discomfort in complaining to staff, understanding that the kitchen had run out of requested items. These incidents highlight a pattern of unmet food preferences and meal discrepancies for several residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to food safety and sanitation guidelines, which posed a risk of foodborne illness to 115 of 116 residents who consumed food prepared in the facility's kitchen. The cool down process for time and temperature control of safety foods was not monitored, as confirmed by the Certified Dietary Manager (CDM), who admitted to not using a cool down log for ambient food items like tuna or chicken salad. Additionally, the dish machine's wash and rinse temperatures did not meet the manufacturer's guidelines, and the facility lacked chlorine test strips to ensure proper sanitization. Observations revealed that staff did not wear appropriate hair restraints, and food preparation equipment was not in proper working order. The can opener blade was worn, and rubber spatulas were chipped and discolored, yet they were still used in food preparation. The facility's kitchen was also found to be unclean, with dirty knife holders, floors, walls, and various kitchen equipment. The CDM confirmed these observations, acknowledging that the equipment and surfaces were not maintained according to the facility's policies. Furthermore, food and kitchen cleaning supplies were not stored properly, with items like cooking oil and brooms being placed on the floor. Non-functioning kitchen equipment, such as broken Robot Coupes, were not discarded and remained in the kitchen. These deficiencies highlight a significant lapse in maintaining a safe and sanitary environment for food preparation, which could potentially lead to foodborne illnesses among the residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their medical and personal needs. Resident 19 experienced a significant unplanned weight loss of 23 pounds, which was not reflected in their care plan. The Registered Dietitian confirmed that the care plan should have been updated to address this weight change, but it was not. Resident 36 also experienced unplanned weight loss and a room change, neither of which were updated in their care plan. The Resident Care Manager acknowledged that the care plan should have included the resident's preference for bathroom assistance and addressed the weight loss with a Nutritional at Risk Assessment, which was not completed. Resident 112's care plan lacked updates for end-of-life care after choosing Hospice services, and there was a lack of communication between the facility and the Hospice agency. Similarly, Resident 121's care plan was not revised to include a new UTI diagnosis, despite an active order for antibiotics. The Director of Nursing confirmed that the care plans for these residents were not developed, reviewed, or revised as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate activities of daily living (ADLs) care for three dependent residents, leading to deficiencies in personal hygiene and grooming. Resident 2, who has contractures, diabetes, quadriplegia, and a cognitive deficit, was observed with long, jagged fingernails that were pressing into his hand due to contractures. This was confirmed by both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN), who acknowledged the need for nail trimming, especially given the resident's diabetes and risk of skin problems. Resident 29, with diagnoses including anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, was also found with long, jagged fingernails. The resident expressed a desire for nail trimming, which was confirmed by multiple CNAs and the Director of Nursing (DON), who admitted that the facility's nail care policy was not followed. Resident 29 was totally dependent on staff for all ADLs and unable to participate in interviews due to a moderate cognitive deficit. Resident 112, with severe cognitive deficits and multiple health issues such as adult failure to thrive, heart disease, and diabetes, did not receive scheduled showers as per the facility's policy. Records showed that out of eight scheduled showers in August and September, only a few were completed, with no refusals documented. The DON confirmed that the facility failed to ensure Resident 112 received the required showers, and any refusals should have been documented and followed up by the LNs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the presence of expired medications and an expired Emergency Drug Kit (E-Kit) in the [NAME] Unit medication room. During an observation, it was found that two bottles of unopened Acetaminophen, a nasal decongestant spray, and an E-Kit containing various antibiotics and intravenous solutions had expired. These expired medications were still available for resident use, which could potentially compromise the safety and effectiveness of treatments provided to residents. The Director of Nursing (DON) acknowledged that a medication review for expired medications should be conducted monthly. However, despite this schedule, expired medications were still present. The DON admitted uncertainty about why these medications were not removed and stated that nurses should ideally check for expired medications every 2 to 4 weeks, with the consultant pharmacist expected to perform a similar review every 3 months. It was noted that there was no strictly established schedule for these reviews, contributing to the oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below five percent, resulting in a rate of 14.81% during a medication pass. This was observed over two days, involving four medication errors out of twenty-seven opportunities for four residents. The errors included improper administration of medications and failure to follow manufacturer instructions, which could potentially affect the efficacy and safety of the medications administered. One of the errors involved a licensed nurse administering an iron supplement to a resident with milk, which is known to reduce the absorption of iron. The nurse was unaware of this interaction, which is contrary to medical guidelines that advise against consuming iron supplements with calcium-rich foods. Another error involved the improper use of a Breo Ellipta Inhaler for a resident, where the resident covered the vent and did not hold their breath as required, potentially leading to inadequate dosing. Additionally, a registered nurse crushed medications with special coatings for another resident, which is against the facility's policy. The medications included enteric-coated aspirin and delayed-release metoprolol, both of which should not be crushed as it compromises their intended release and absorption. The nurse acknowledged the error and the need to consult with the attending physician for alternative medications that can be safely crushed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a pest-free environment, as evidenced by multiple observations of flies in various areas, including the kitchen, dining room, and conference room. The facility's policy on vermin control, dated April 2018, mandates that the Food and Nutrition Services Department must be free from pests at all times, with arrangements made by the Administrator for an effective pest control program. Despite this, flies were observed in the kitchen near the food preparation sink, in the dish room, and on meal trays, indicating a lapse in pest control measures. Interviews with facility staff revealed a lack of clarity and responsibility regarding the operation of the air curtain, a device intended to prevent flying insects from entering the kitchen. The air curtain was found to be non-operational during the initial observation, and staff members, including the Certified Dietary Manager (CDM) and various dietary aides, were either unaware of their responsibility to operate it or had never done so. The Plant Operations Manager (POM) confirmed that the air curtain should be turned on at all times, but it was not functioning until manually activated during the survey. The CDM also failed to report the fly issue to the POM or the pest control company, further contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the dignity of a resident, identified as Resident 36, by not providing timely assistance with toileting needs. Resident 36, who was admitted with multiple diagnoses including anxiety and depression, was found to be totally dependent on staff for toileting and transfers. Despite having no cognitive deficits and being able to verbalize her needs, Resident 36 reported that staff often delayed responding to her requests for toileting assistance, sometimes making her wait up to an hour. This delay resulted in her being left in a soiled brief, which increased her anxiety and made her feel neglected. Interviews with Resident 36 and facility staff, including the Director of Social Services and the Resident Care Manager, confirmed the resident's feelings of anxiety and the violation of her rights. The Director of Nursing acknowledged that the staff's actions were a violation of the resident's rights and dignity. The facility's policies on dignity and resident rights emphasize the importance of treating residents with respect and promptly responding to their needs, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a comfortable and homelike environment for one of its residents, identified as Resident 29, who was unable to see his wife's pictures due to clutter on his dresser. This deficiency was observed during a survey, where Resident 29 expressed frustration about the clutter, stating that he was accustomed to having things in order. The facility's policy, dated May 2011, emphasizes providing a safe, clean, and homelike environment, encouraging the use of personal belongings. However, the clutter on Resident 29's dresser, which included hygiene products left out in the open, violated this policy and the resident's right to a homelike setting. Interviews with facility staff, including two Certified Nursing Assistants (CNAs) and the Director of Social Services (DSS), confirmed the presence of clutter and acknowledged that Resident 29 was unable to view his personal pictures. The DSS noted that Resident 29, due to his background, preferred orderliness and should be able to see his personal pictures. The Director of Nursing also confirmed that the resident should have a homelike environment, and the clutter should be removed to allow the resident to view his family pictures. Resident 29's medical history includes anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, which may contribute to his need for a personalized and orderly environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nutritional services to Resident 19, as evidenced by the lack of a timely nutritional assessment by the Registered Dietitian (RD) upon the resident's readmission. Despite the facility's policy requiring a nutritional assessment within seven to 21 days of admission, Resident 19's nutritional status was not assessed after readmission. The RD confirmed that there was no system in place to prevent missed nutritional assessments, and the RD was not notified of new admissions in a timely manner. Resident 19 experienced significant unplanned weight loss, which was not addressed by the RD or the Interdisciplinary Team (IDT). The resident's weight decreased from 215.4 lbs. to 192.4 lbs., a 10.6% loss over six months, which was not documented or addressed in the Nutrition at Risk (NAR) meetings. The RD and Licensed Nurse (LN) 8 confirmed that the weight loss was not communicated or documented properly, and there was no evidence of IDT meetings to address the issue. Additionally, the facility did not obtain Resident 19's admission weight in a timely manner, as required by their policy. The resident was not weighed until four days after readmission, which delayed the identification and intervention for the resident's weight loss. The RD and LN 8 confirmed that there was no documentation of a care plan to address the severe unplanned weight loss, and the resident's nutritional needs were not adequately monitored or managed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with federal regulations regarding the educational qualifications of the dietary manager, as specified in the California Code, Health and Safety Code (HSC 1265.4). This deficiency was identified during an interview with the Certified Dietary Manager (CDM), who stated that he received his CDM certificate from the University of Florida. However, he confirmed that he had not received the specific California dietary service requirements contained in Title 22 of the California Code of Regulations before assuming full-time duties as a dietetic services supervisor at the health facility. This oversight had the potential to result in inadequate oversight of the food and nutrition services department, which could affect meal distribution accuracy, safe food handling, and adherence to sanitation guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the appropriate textured diet for one resident, identified as Resident 48, who was supposed to receive chopped meat as part of an Easy to Chew diet. During a lunch meal observation, Resident 48 was served pork pieces that were approximately one to one and a half inches in size, which did not meet the facility's diet manual specifications for chopped meat, defined as 1/4 inch to 1/2 inch pieces. This discrepancy was noted when Resident 48 was observed to have chewed and spit out a piece of pork, expressing dislike for the meat. The Certified Dietary Manager (CDM) was interviewed and confirmed that a Regular chopped meat diet was not listed on the therapeutic spreadsheet, which outlines the specifics of each diet type. Furthermore, the CDM admitted to not knowing the specific size requirements for chopped meats and indicated a need to refer to the diet manual for this information. This lack of knowledge and adherence to the diet manual's guidelines contributed to the failure in providing the appropriate diet texture for Resident 48.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of garbage and refuse, which had the potential to attract insects and rodents, affecting all 116 residents. During an initial tour of the kitchen, more than ten broken down cardboard boxes were observed on a kitchen cart and two additional boxes were found next to a food preparation table. The Certified Dietary Manager (CDM) confirmed that these boxes were collected in the kitchen and only taken outside at the end of the shift. Additionally, outside the kitchen door, various items such as dietary carts, linen carts, mattresses, and wheelchair parts were found near a portable storage container next to the kitchen loading dock. The Plant Operations Manager (POM) stated that no one was assigned to pick up trash in this area. The Administrator (ADM) confirmed that there was no specific person in charge of the area outside the kitchen door, and acknowledged that trash should not be present there. The ADM mentioned that the POM was responsible for taking items that needed to be discarded to the dump.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate care needs with a Hospice agency for a resident receiving end-of-life care. The resident, who had severe cognitive deficits and was dependent on staff for all activities of daily living, was admitted to the facility with multiple diagnoses, including adult failure to thrive, heart disease, and diabetes. Despite being under Hospice care, there was a lack of communication between the facility and the Hospice agency, resulting in the resident not receiving necessary personal care, such as showers or baths, as required by the facility's policy. Interviews with facility staff and the Hospice agency revealed that the facility did not update the resident's care plan to reflect current needs, nor did they coordinate with the Hospice agency to ensure the resident's comfort and symptom management. The Director of Patient Care from the Hospice agency confirmed that the plan for end-of-life care had been sent to the facility, but the facility failed to communicate any changes or coordinate care effectively. This lack of coordination and communication led to a delay in personal care and had the potential to cause emotional stress and negative clinical outcomes for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse by a registry staff member. The incident involved a resident with a medical history that includes hemiplegia and hemiparesis following a cerebral infarct, vascular dementia, and kidney cancer. During care, a registry staff member aggressively grabbed the resident's wrists, which was confirmed by both the resident and a Certified Nursing Assistant (CNA) who witnessed the event. The facility's policy on abuse prevention, dated December 2020, explicitly states that residents have the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff from other agencies. Interviews conducted with the resident, CNA B, and CNA C revealed that the registry staff member grabbed the resident's wrists and pushed them down to the resident's chest while speaking in an aggressive tone. The registry staff member admitted to grabbing the resident's wrists to avoid the resident's attacks. The facility's administration confirmed that the incident occurred and was substantiated through their investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from verbal abuse when a Certified Nursing Assistant (CNA) cursed at her while providing care. The incident involved a resident with diagnoses including intracranial hemorrhage, anxiety, and dementia. The California Department of Public Health received a report of possible verbal abuse by CNA 1 towards the resident. Another staff member witnessed CNA 1 calling the resident a derogatory term. CNA 1 was immediately suspended and later terminated. The resident had no recollection of the incident due to her dementia. During the investigation, it was revealed that the resident became combative during care, leading CNA 2 to request assistance from CNA 1. The resident's aggression escalated, and CNA 1 responded by making an inappropriate comment. CNA 1 admitted to the verbal abuse, citing personal stress as a contributing factor. The Director of Staff Development confirmed that CNA 1 was remorseful and acknowledged her wrongdoing.