Miracle Mile Healthcare Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1020 South Fairfax Ave, Los Angeles, California 90019
- CMS Provider Number
- 555139
- Inspections on file
- 78
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Miracle Mile Healthcare Center, Llc during CMS and state inspections, most recent first.
A resident with incontinence, impaired mobility, and communication deficits related to a prior stroke was not assigned a CNA on an overnight shift, despite needing partial assistance with toileting and transfers. As a result, the resident was not checked for several hours and was later found by an LVN sitting on the floor in feces. CNAs cleaned the resident while the resident remained on the floor but were unable to lift the resident back to bed, and the RN supervisor did not assist before the end of the shift. The resident remained on the floor until the next shift arrived to complete the transfer, and leadership was not promptly notified, contrary to facility abuse/neglect policies.
A resident with complete paraplegia and high dependence for ADLs was care planned and ordered to use a low air loss (LAL) mattress for skin impairment prevention, with nursing staff required to monitor its placement and functioning each shift per the manufacturer’s Dynarex manual. During an observation, an LVN responding to a call light found the LAL mattress alarm sounding and the low-pressure indicator flashing, and discovered the mattress was incorrectly set at 350 lbs instead of the resident’s actual weight of 106 lbs. The LVN stated the treatment nurse was responsible for verifying correct settings, and the DON acknowledged that an incorrectly set LAL mattress can adversely affect skin management and pressure injury prevention.
A resident with incontinence, impaired mobility, OA, and a high fall risk had care plans requiring q2h checks for toileting, prompt response to assistance requests, and use of floor mats for safety. On an overnight shift, no CNA was assigned to the resident due to an error on the CNA assignment sheet, and the charge LVN did not make rounds until early morning, when the resident was first found on the floor. Later, CNAs found the resident still on the floor, sitting in feces, and were unable to lift the resident, who remained there until the next shift arrived. Leadership was not notified of the fall or the assignment error, no timely investigation was initiated as required by facility policy, and an observation on a later date showed that ordered floor mats were not in place in the resident’s room.
A resident with paraplegia, intact cognition, and dependence on staff for toileting and most ADLs was left in the same incontinent brief for approximately three days, despite a care plan requiring brief changes every two hours and as needed with perineal cleansing after each incontinence episode. A CNA had dated and initialed the brief when it was applied due to concern that staff were not changing the resident as required, and upon returning from days off, found the same brief still in place. This failure to follow the resident’s care plan and facility policies on ADLs and fecal incontinence resulted in the resident remaining soiled for an extended period, which the DON stated increased risk for skin breakdown and compromised dignity.
A resident with dementia and psychiatric disorders, known for exit-seeking and aggressive behaviors, was not properly assessed for elopement risk and did not have an updated care plan or adequate supervision. Despite multiple episodes of exit-seeking, staff failed to provide continuous 1:1 monitoring, resulting in the resident breaking a window and sustaining serious leg fractures that required hospitalization and surgery. Staff interviews revealed lapses in assessment, supervision, and documentation, as well as allegations of pressure to falsify incident reports.
A resident with a history of mental health disorders exhibited escalating aggressive and erratic behavior, including attempts to elope and physical aggression. Despite staff reporting these behaviors, the response was limited to medication administration without hospital transfer. The resident subsequently broke a window, fell, and sustained severe leg fractures, requiring emergency hospital care. Another resident in the same room reported feeling unsafe and disturbed by the incident.
A resident with multiple medical conditions was placed in a room with a broken window, resulting in exposure to cold temperatures for two days. The window was not repaired promptly, extra blankets were not provided, and the resident was not moved to another room. Staff confirmed incomplete temperature logs and lack of timely maintenance, contrary to facility policy.
A window in a resident room was observed open with a large hole in the screen, allowing insects to enter. A CNA and the infection preventionist confirmed that the damaged screen permitted flies and mosquitoes into the room, contrary to facility policy requiring a safe and sanitary environment.
A resident who was cognitively intact and required moderate assistance with ADLs was unable to reach the call light, which was found on the floor and out of reach. The resident reported calling for help for several hours without response, and staff confirmed the call light was not accessible as required by facility policy.
A resident with multiple chronic conditions requiring significant assistance was observed wearing soiled clothing and lacking proper incontinence care, with personal items and linens left unclean. The resident expressed feelings of embarrassment and neglect, and staff confirmed that the resident's dignity and rights were not upheld according to facility policy.
A facility failed to develop a care plan for a resident with memory problems, despite the resident's admission record indicating severe cognitive impairment and a history of memory issues. The resident required assistance with activities of daily living, and an LVN confirmed that a care plan should have been created. The facility's policy mandates comprehensive care plans, but this was not implemented for the resident.
A facility failed to ensure timely physician visits for a resident with complex medical conditions, as required by regulations. The resident, with diagnoses including schizophrenia and diabetes, did not receive face-to-face visits from the attending physician after a certain date, despite facility policy requiring regular visits. This was confirmed through interviews and record reviews, revealing a lapse in adherence to the required visit schedule.
A resident missed a medical appointment due to the facility's failure to arrange timely transportation. Despite notifying staff two weeks in advance, the transport arrived late, leading to the appointment's cancellation. The DSS admitted the issue could have been avoided with prior confirmation of transportation arrangements.
A cognitively impaired resident in an LTC facility was not provided with the required 80 square feet of living space in a shared room. The resident's space was reduced to 48.44 square feet due to another resident's belongings encroaching on their area. The Maintenance Director and Facility Administrator confirmed the deficiency, acknowledging the potential impact on privacy, dignity, and safety.
A facility failed to address a persistent ceiling leak in a room occupied by two residents, creating a fall risk due to water accumulation on the floor. Despite multiple repair attempts, the leak continued, and the residents were not relocated. Staff acknowledged the safety hazard, but only temporary measures were taken, contrary to the facility's policy of maintaining a hazard-free environment.
The facility failed to maintain a safe environment by not addressing water leaks in a room occupied by two residents, leading to potential safety hazards. Despite reports of the issue, the residents were not relocated, and repairs were unsuccessful. Additionally, a malfunctioning thermostat affected temperature control in multiple rooms, potentially compromising residents' health and comfort.
The facility's elevator was frequently malfunctioning, causing staff to get stuck and requiring frequent resets by a Monitor Aide. The issue, known to the Maintenance Supervisor, Administrator, and Nursing Supervisors, had persisted for at least a year. An urgent inspection was conducted, but repairs had not been made. The facility's maintenance policy requires equipment to be safe and operable, which was not met.
The facility failed to document advance directives for three residents, potentially conflicting with their healthcare wishes. Despite having intact or moderately impaired cognition, these residents did not have advance directives in their medical records. The absence of these documents was confirmed by staff, highlighting a failure to adhere to the facility's policy requiring completion within 72 hours of admission.
The facility failed to properly store and dispose of controlled and non-controlled medications, as required by its policy. Expired medications were destroyed by night shift nurses instead of the DON, and the storage container for narcotics was not securely locked. The facility also lacked proper records of medication disposal, contrary to its policy.
The facility was found deficient in maintaining safe food storage and preparation practices. Personal items were placed on a prep sink, hashbrowns in the freezer were not labeled with open dates, and a Dietary Aide failed to wash hands between handling dirty and clean dishes, risking cross-contamination. The DON highlighted the importance of labeling to prevent serving expired foods.
The facility failed to maintain an industrial washing machine, essential for providing clean linen to 111 residents. One of two machines was out of service for a month, with no part ordered or repair scheduled, potentially delaying linen delivery and causing resident frustration.
The facility failed to obtain informed consent from two residents before starting psychotropic medications. One resident had moderate cognitive impairment, while the other had intact cognition. In both cases, consent forms lacked the residents' signatures and proper verification by a nurse, violating facility policy.
A resident was left feeling uncomfortably cold in bed without adequate coverings due to the facility's failure to provide a homelike environment. The resident, who was cognitively intact and required assistance with daily activities, was observed without a top sheet, blanket, or pillowcase. A CNA removed the linen in the morning but did not replace it due to a lack of clean linen available. The DON confirmed the importance of a homelike environment, which includes having a fully made bed with clean linen.
A resident with cerebral palsy and muscle wasting did not receive adequate assistance with ADLs, such as bathing and toileting, due to staff inaction and lack of documentation. The resident reported long waits for care and was left in soiled conditions, while the facility's policy required assistance for those unable to perform ADLs independently.
A facility failed to provide proper colostomy care for a resident, resulting in skin excoriation and potential infection risk. The resident, admitted with colostomy malfunction, reported that their colostomy bag was not changed as needed, leading to skin irritation. An LVN confirmed the issue, and the Treatment Nurse noted that timely changes were necessary to prevent skin breakdown and infection. The facility's policy aimed to prevent skin exposure to fecal matter, but it was not followed in this instance.
A facility failed to complete post-hemodialysis assessments for a resident with ESRD, who required dialysis services. The resident's care plan included monitoring vital signs and reporting signs of infection at the access site. However, post-dialysis assessments were missing on several occasions, and there were no progress notes documenting these assessments. The DON acknowledged that this failure could result in not addressing changes in the resident's health condition.
A facility failed to ensure the retrieval of a resident's personal belongings from a previous skilled nursing facility. The resident, with multiple health conditions, expressed frustration over the lack of assistance from the social service designee, who was unable to provide documentation or specific details about the belongings' transfer. This oversight had the potential for the resident's property to be misplaced or lost.
The facility staff failed to follow infection control protocols, with a clean bedside table, linen, and wheelchair improperly stored in a resident's bathroom, and an LVN exiting a room with gloves and medication in hand. These actions risked cross-contamination and infection spread.
A resident in the facility was found to have a broken trim, missing closet knobs, and an exposed wire in their room, which were present upon admission. The Maintenance Assistant confirmed these issues and noted a lack of guidance following the recent resignation of the Maintenance Supervisor. The resident, who has mild cognitive impairment and requires assistance with daily activities, expressed frustration over the unaddressed repairs.
A staff member at the facility, hired in June 2024, did not receive mandatory abuse training until December 2024, after an abuse allegation was made by a resident. The facility's policy requires such training upon hire to prevent and identify abuse, neglect, and exploitation. This oversight was confirmed by the staffer responsible for scheduling and the DON, highlighting a lapse in the facility's training protocol.
A resident with hypertensive heart disease did not have clonidine administration properly documented on three occasions when their SBP exceeded 160. The LVN involved claimed to have administered the medication but failed to document it in the MAR, contrary to the facility's policy requiring immediate documentation. This placed the resident at risk for uncontrolled blood pressure.
A resident in an LTC facility was slapped twice on the cheek by a CNA, who then laughed at the resident. The incident was reported to the police by the resident, who felt violated and vulnerable. The facility's investigation confirmed the incident, despite having policies in place to prevent abuse.
A resident with cognitive impairments and a history of mental health issues eloped from the facility and was later found deceased. The facility failed to implement the care plan, monitor changes in behavior, and supervise the resident effectively. The resident's elopement was not immediately recognized, and there were delays in notifying the family, physician, and law enforcement.
The facility failed to maintain a consistent Director of Nursing (DON) over the past two months, with the last two hires quitting after short tenures. This inconsistency potentially affected resident care and clinical outcomes, as the DON is responsible for critical functions such as developing nursing objectives, maintaining policy manuals, and ensuring care is administered according to residents' assessments and care plans.
Two residents experienced discomfort due to cold room temperatures at night, and an ammonia-like odor was noted in the nursing unit. Both residents, who were cognitively intact and required assistance with ADLs, reported difficulty sleeping due to the cold. The facility's policy emphasizes maintaining a clean, odor-free environment with comfortable temperatures, which was not upheld.
A resident who was continent of bladder and bowel did not receive timely toileting assistance, resulting in a soaked incontinence brief and an ammonia-like smell in the room. Despite being cognitively intact and requiring substantial assistance, the resident's request for a change was delayed by a CNA, who admitted to waiting for additional help. The facility's policy on resident rights, which includes timely care, was not followed.
A resident with cerebral palsy, muscle wasting, and osteoporosis fell and sprained her ankle during ADL care when a CNA failed to use a required two-person assist. Despite being familiar with the resident's needs, the CNA attempted to turn the resident alone, leading to the fall. The facility's policy required interventions to prevent falls, which were not followed in this instance.
A resident with a documented coconut allergy was served chocolate cake containing coconut, despite the allergy being highlighted on the food tray card. The oversight occurred due to a lack of proper checks by kitchen staff and LVNs, as confirmed by interviews with the CNA, RD, and DS. The facility's policy on food allergies was not effectively followed, leading to the resident receiving potentially harmful food.
A resident with a history of falls and high fall risk due to dementia and other conditions experienced multiple falls, culminating in a serious injury. Despite being identified as high risk, the facility failed to adequately monitor and modify interventions, leading to repeated incidents. The resident's care plans were not consistently updated, and staff were unaware of the resident's fall history, resulting in insufficient supervision and a traumatic head injury.
The facility failed to maintain accurate and complete medical records for two residents, with missing entries in the MAR and incomplete informed consent forms. A resident's MAR had gaps in medication and dietary documentation, while informed consent forms lacked necessary signatures and dates. The ADON confirmed these deficiencies, highlighting the importance of complete documentation as per facility policy.
A resident with metabolic encephalopathy, acute psychosis, and anxiety disorder was not provided adequate care for personal hygiene and room cleanliness. The resident, requiring moderate assistance for daily activities, was found sitting on the floor with trash and belongings scattered, refusing help and becoming aggressive. Staff interviews revealed no care plan for the resident's noncompliance, posing a safety issue contrary to facility policy.
The facility failed to provide care according to professional standards for eight residents by not checking blood sugar levels before meals and administering insulin late or not at all. This led to potential risks of unmanaged blood glucose levels and associated complications.
The facility failed to ensure that staff had the necessary competencies and certifications, including BLS/CPR, potentially compromising resident safety. One nurse lacked an updated BLS/CPR certification, and two nurses were missing skills check competencies, as confirmed by the Director of Staff Development.
A resident experienced increased paranoia and refused medications, but the facility failed to notify the physician, delaying necessary interventions. The resident's Keppra level was below therapeutic range after a seizure, and documentation lapses in the MAR contributed to the oversight.
A resident with schizophrenia did not receive Risperdal as prescribed, leading to increased paranoia and hospitalization. The facility failed to notify the physician of the resident's medication refusal and did not conduct required medication reviews or dose reductions.
A facility failed to document medication administration immediately after each pass, as observed during a medication pass by an LVN. The LVN administered medications to several residents with various medical conditions but did not document in the MAR immediately, citing workload as a reason. The ADON confirmed that this practice deviated from the facility's policy, which requires documentation after each medication pass to prevent medication errors.
A resident with acute psychosis and anxiety disorder did not receive Risperdal as prescribed, and the facility failed to notify the physician of the resident's refusal and psychosis episodes. The care plan lacked interventions for medication non-compliance, and facility policies on behavioral assessment and treatment refusal were not followed.
A resident with multiple health conditions was observed with a Foley catheter bag dragging on the floor, posing a risk of infection. Despite the presence of staff, no immediate action was taken until later intervention by the ADON, contrary to the facility's catheter care policy.
Resident Left Unassigned and Unattended on Floor in Feces Overnight
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring that staff checked on the resident every two hours for toileting and care needs during an overnight shift. The resident had diagnoses including metabolic encephalopathy, incontinence, impaired mobility, osteoarthritis, and communication deficits related to a previous stroke. An MDS dated 12/31/2025 documented that the resident had intact cognition for daily decision-making, required partial assistance for toileting, dressing, toilet transfers, and walking, and used a wheelchair for mobility. The resident also required supervision for multiple ADLs, including bathing, hygiene, transfers, and positioning. On the 11 PM to 7 AM shift, the CNA assignment sheet for that night did not list any CNA assigned to this resident. CNA1 stated that he was not assigned to the resident and that the assignment sheet did not reflect any staff responsible for the resident’s care. As a result, the resident was not checked or assisted with toileting or incontinent care for an extended period. According to interviews, at approximately 5 AM, LVN2 found the resident in her room sitting on the floor in feces and informed the RN Supervisor. CNA1 later went to assist the resident around 6:20 AM after being instructed by the RN Supervisor and found the resident still on the floor, sitting in stool with feces on her body. CNA1 and CNA3 cleaned the resident while she remained on the floor but were unable to lift her back into bed due to her weight and inability to assist with the transfer. CNA1 reported that the RN Supervisor declined to help, stating it was almost the end of his shift, and provided no assistance. CNA1 further stated that he informed the RN Supervisor that he and CNA3 were ending their shift while the resident remained on the floor. LVN2 confirmed that the resident stayed on the floor from the time she was found at approximately 5 AM until the morning shift arrived at 7 AM to assist with lifting and transferring the resident back to bed. The DON and DSD reported that they were not notified at the time of the incident, and the DON stated that no licensed nurse had informed her that the resident was found on the floor, so no root cause analysis or investigation had been conducted. Facility policies on abuse prevention and reporting defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required prompt and thorough investigation of neglect or injuries of unknown source.
Improper Low Air Loss Mattress Setting for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a low air loss (LAL) mattress was set according to the manufacturer’s weight-based guidelines for a resident with significant skin integrity risk. The resident, admitted with complete paraplegia and dependent or requiring extensive assistance for most ADLs, had an active care plan and physician order directing use of a LAL mattress for skin impairment prevention, with licensed nurses to monitor placement and functioning every shift. The manufacturer’s Dynarex LAL mattress manual specified that mattress settings should correspond to patient weight and that a low-pressure light and alarm would activate when pressure fell below the preset level. During an observation and interview, an LVN responded to the resident’s call light and found the LAL mattress alarm sounding and the low-pressure indicator flashing red. On inspection, the LVN identified that the mattress was incorrectly set at 350 lbs, while the resident’s actual weight was 106 lbs. The LVN stated the mattress should have been set to the resident’s current weight and that the treatment nurse was responsible for verifying correct settings during rounds. The DON confirmed that an incorrectly set LAL mattress can negatively impact a resident’s skin management and overall pressure injury prevention plan. The facility’s ADL policy required provision of hygiene and toileting services and interventions in accordance with assessed needs and recognized standards of practice, but the mattress setting and monitoring did not follow the manufacturer’s instructions or the resident’s care plan and orders.
Failure to Follow Fall-Risk Care Plan, CNA Assignment, and Safety Orders Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow an identified fall-risk and incontinence care plan and physician orders for a resident with multiple risk factors, resulting in an unwitnessed fall and prolonged time on the floor. The resident was admitted with incontinence, impaired mobility, and osteoarthritis, and an MDS dated 12/31/2025 showed intact cognition but a need for partial assistance with toileting and transfers, and supervision for multiple ADLs. Care plans initiated in March 2025 identified the resident as at risk for falls related to incontinence and unawareness of safety needs, with interventions including placing floor mats for safety, keeping the bed in the lowest position, anticipating and meeting needs, promptly responding to requests for assistance, and checking the resident every two hours to assist with toileting and provide pericare after each incontinent episode. A fall risk evaluation dated 1/6/2026 identified the resident as a high fall risk requiring assistive devices and taking 1–2 medications that increased fall risk. On the night shift spanning 1/9/2026 to 1/10/2026 (11 PM–7 AM), the CNA assignment sheet contained an error in that no CNA was assigned to this resident, despite the resident’s identified needs for assistance and supervision. CNA staff later reported that when asked to provide care to the resident at approximately 6:20 AM, they reviewed the CNA assignment sheets for 1/9/2026 and 1/10/2026 and confirmed that no CNA had been assigned to the resident. LVN2, who was the charge nurse on that shift, stated that at approximately 5 AM it was the first time during that shift that she made rounds and found the resident sitting on the floor in her room. LVN2 reported that she notified the RN Supervisor and that no one responded to help her lift the resident until the 7 AM day shift arrived, noting that at least two staff were required to lift the resident due to a weight of 224 pounds. When CNA1 and another CNA went to provide care at about 6:20 AM, they found the resident on the floor sitting in feces and were unable to lift her, informing the RN Supervisor and LVN2. CNA1 reported that he and the other CNA signed out at 7 AM, leaving the resident on the floor until the oncoming shift lifted her. The facility’s Director of Nursing stated that no licensed staff informed her that the resident was found on the floor, so no root cause analysis or investigation was initiated. The Director of Staff Development stated she was not informed of the CNA assignment error and that issues affecting residents were required to be communicated immediately to leadership. A physician order summary dated 1/12/2026 directed that floor mats be placed for safety, and the care plan dated 1/12/2026 reiterated that floor mats would be placed as indicated; however, an observation on 2/3/2026 showed that the resident’s room did not have floor mats in place. Facility policies on falls and on accident/incident investigation required that a resident found on the floor be considered to have had a fall and that an investigation be initiated and documented within 24 hours, but this was not done for this event.
Failure to Provide Timely Incontinent Care and Brief Changes
Penalty
Summary
Surveyors identified that staff failed to provide incontinent care and pressure injury prevention for one resident over an approximately three-day period. The resident had complete paraplegia, intact cognition, and was dependent on staff for toileting, lower body dressing, transfers, and most ADLs, with a care plan directing that disposable briefs be changed every two hours and as needed, and that the perineal area be cleaned after each incontinence episode. On one early morning, CNA 1 provided incontinent care, applied a clean brief, and wrote his initials, time, and date on the brief because he was concerned that staff were not changing this resident as required. CNA 1 was then off duty for several days. When CNA 1 returned to work, he observed that the resident was still wearing the same incontinent brief he had applied days earlier, with the same date and time markings, indicating that the brief had not been changed during that period. Interviews with the DON and DSD confirmed their awareness that the resident had been left soiled and in the same brief for about three days, despite the resident’s history of refusal of ADLs. Facility policies on ADLs and fecal incontinence required that residents be provided hygiene and toileting services in accordance with assessed needs and that residents be cleaned after each episode of incontinence, with refusals reported to a supervisor. The failure to follow the care plan and policies resulted in the resident remaining in the same incontinent brief for days, which the DON stated placed the resident at increased risk for skin breakdown and affected his dignity.
Failure to Assess and Supervise Resident with Elopement Risk Resulting in Severe Injury
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with a history of dementia, major depressive disorder, and psychosis, who exhibited exit-seeking and aggressive behaviors. Upon initial admission and subsequent readmission, the facility did not complete or properly document the required Wandering Risk and Elopement Screening Assessment. Despite multiple episodes of exit-seeking and attempts to leave the facility, the resident's care plan was not updated to reflect these behaviors, and no comprehensive elopement prevention plan was developed. On several occasions, staff observed the resident attempting to leave the facility, displaying delusional and aggressive behaviors, and expressing a desire to go home. Staff interviews revealed that the resident was known to be confused, at risk for elopement, and had previously attempted to access exits. On the day of the incident, the resident became agitated, climbed onto her bed, and began kicking a window in an attempt to escape. Although a 1:1 sitter was ordered, the assigned LVN was also responsible for 28 other residents and did not request additional staff support. The LVN did not continuously monitor the resident, and there was confusion among staff regarding who was providing direct supervision at the time of the incident. As a result of inadequate supervision and failure to intervene, the resident broke the window and sustained severe injuries, including a right tibial plateau fracture and a comminuted fracture of the fibular head and neck, requiring hospitalization and surgical intervention. Documentation and interviews further revealed that staff failed to follow up on psychiatric consult orders and did not implement immediate safety strategies as outlined in facility policies. There were also allegations of staff being pressured to falsify statements regarding the incident.
Failure to Provide Timely Behavioral Health Intervention Resulting in Resident Injury
Penalty
Summary
The facility failed to provide necessary and appropriate behavioral health care and services to a resident experiencing a mental health crisis. The resident, who had a history of major depressive disorder, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, exhibited aggressive and erratic behavior, including attempts to elope and physical aggression. Despite these behaviors being reported by staff at the beginning of the shift, the response was limited to notifying the psychiatric nurse practitioner, who ordered a one-time dose of intramuscular Haldol and Benadryl. No order for hospital transfer was given at that time, and the resident's behavior continued to escalate. During the shift, the resident climbed onto a nightstand and broke a window with a metal object, subsequently falling and sustaining a severe injury to the right leg. Staff responded after hearing calls for help, and upon assessment, noted swelling and severe pain in the resident's right leg. Emergency services were called, and the resident was transferred to a general acute care hospital, where imaging confirmed acute, displaced fractures of the right tibia and fibula, requiring surgical intervention. The incident was witnessed by another resident, who reported feeling unsafe and disturbed by the aggressive behavior and was relieved when the resident was moved to another room. Interviews with staff revealed that the aggressive and elopement behaviors had been reported but not acted upon with sufficient urgency. The Director of Nursing acknowledged that the incident could have been avoided if the resident had been transferred for evaluation earlier, given the repeated attempts to elope and escalating aggression. The facility's policy required prompt investigation and documentation of such incidents, but the actions taken were not adequate to prevent harm to the resident and distress to others.
Failure to Maintain Safe and Comfortable Resident Environment Due to Broken Window
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident by admitting and keeping the resident in a room with a broken window, resulting in exposure to cold temperatures for two days and nights. The broken window was not repaired in a timely manner, and the resident was not provided with extra blankets or moved to another room without a broken window. The resident reported feeling very cold and angry due to the conditions, and the room temperature was observed to be very cold during the survey. The resident involved had a history of heart failure, bipolar disorder, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired but able to ambulate independently and required varying levels of assistance with activities of daily living. Despite these vulnerabilities, the resident was left in a room with a large hole in the window, which allowed cold air to enter and created an uncomfortable and potentially unsafe environment. Facility staff, including the Maintenance Director and DON, confirmed that the window had been broken for several days and that temperature logs were incomplete or unavailable. The Maintenance Director had not ordered a replacement window until the day of the survey, and there was a lack of documentation regarding daily room temperature checks. The facility's own policy required maintenance to keep the building in good repair and free from hazards, but these procedures were not followed in this instance.
Failure to Maintain Window Screen in Good Repair
Penalty
Summary
The facility failed to maintain a window screen in good repair in one of six sampled resident rooms (Room A). During an observation, the window in Room A was found open with a large hole in the lower corner of the screen. A CNA confirmed that the window was open for ventilation and acknowledged that the hole allowed insects such as flies and mosquitoes to enter the room and reach the residents. The infection preventionist also confirmed that a hole in the window screen could allow insects to enter the resident's room. Review of the facility's policy indicated that residents are to be provided with a safe, clean, and comfortable homelike environment, including maintaining a clean and sanitary setting.
Call Light Not Kept Within Reach for Resident
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for one of three randomly selected residents. Resident 3, who was cognitively intact and required partial to moderate assistance with activities of daily living, was observed and interviewed after she had been calling out for help for approximately four hours without response. The call light, which is the primary method for residents to request assistance, was found on the floor and out of her reach. Resident 3 reported that this was a common occurrence and that she was unable to get help when needed, specifically mentioning discomfort due to bunched-up clothing that she could not adjust herself. Staff interviews confirmed that the call light was not accessible to the resident, and both the Registered Nurse Supervisor and the Director of Nursing acknowledged that call lights must be within reach to allow residents to request assistance for their needs. A review of the facility's policy and procedures also indicated that staff are required to ensure call lights are accessible to residents at all times. The failure to keep the call light within reach was directly observed and confirmed by staff, and was not in accordance with the facility's established procedures.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
Facility staff failed to promote dignity and respect for a resident by not providing clean clothing, linens, and timely incontinence care. The resident, who had diagnoses including End Stage Renal Disease, dependence on hemodialysis, and chronic obstructive pulmonary disease, required moderate to maximal assistance with most activities of daily living. During observation, the resident was found in the hallway with unzipped pants and a stained t-shirt, and reported feeling embarrassed and uncared for due to lack of staff assistance in maintaining a presentable appearance, especially when attending dialysis appointments. The resident also stated that incontinence briefs were often left soiled for extended periods, leading to periods without any incontinence protection. Further observation revealed the resident's clothing strewn on the floor and a bed with a large yellow stain on the sheets. A Licensed Vocational Nurse confirmed the resident's unkempt appearance and acknowledged that the resident's rights and dignity were not being honored. The Director of Nursing also stated the importance of cleanliness for hygiene and dignity. Facility policies reviewed indicated that residents should be provided with a clean, comfortable, and homelike environment, and be treated with respect and dignity, which was not upheld in this instance.
Failure to Develop Care Plan for Resident with Memory Problems
Penalty
Summary
The facility failed to develop a care plan for a resident with a history of memory problems. This deficiency was identified during a review of the resident's admission record, which indicated diagnoses including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, and hypertensive heart disease. The Minimum Data Set (MDS) assessment revealed that the resident's cognitive skills for daily decisions were severely impaired, and the resident required assistance for activities of daily living, such as toilet transfers and walking, although they were independent with bed mobility. Despite the resident's history of memory problems and noncompliance noted in the Baseline Care Plan, no comprehensive care plan was developed to address these issues. An interview with an LVN confirmed that a care plan should have been created if memory problems were present upon admission. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, but this was not implemented for the resident in question.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the attending physician conducted face-to-face visits with a resident as required by regulations. Specifically, for one resident, the attending physician did not make the necessary visits after a certain date, despite the resident having complex medical conditions and cognitive impairments. The resident was admitted with diagnoses including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, and hypertensive heart disease. The Minimum Data Set indicated that the resident had severely impaired cognitive skills and required assistance with activities of daily living. During interviews and record reviews, it was confirmed that there were no physician progress notes in the resident's medical record after a specific date, indicating a lapse in required visits. The facility's policy stated that the attending physician must visit residents at least once every thirty days for the first ninety days following admission, and then at least every sixty days thereafter. However, the physician did not adhere to this schedule, as verified by the Medical Records Director, who confirmed the absence of physician notes after the specified date.
Failure to Arrange Timely Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to honor a resident's right to be seen by a physician by not arranging reliable transportation, resulting in the resident missing a scheduled medical appointment. The resident, who was cognitively intact and independent in activities of daily living, had informed the facility staff about the appointment two weeks in advance. Despite confirmation from the staff that transportation was arranged, the transport arrived late, causing the appointment to be canceled. The Director of Social Services (DSS) acknowledged that the resident had notified the facility about the appointment and that transportation was arranged through the resident's insurance for a 10 am pickup. However, on the day of the appointment, the DSS discovered that the transportation had been canceled and had to arrange for an alternative, which arrived too late. The DSS admitted that the issue could have been avoided if the facility staff had confirmed the transportation arrangements one or two days before the appointment. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and supporting them in exercising their rights, which was not upheld in this instance.
Inadequate Living Space for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate living space for Resident 4, who was cognitively impaired and dependent on assistance for all activities of daily living. Resident 4 was placed in a semiprivate room that did not meet the required minimum of 80 square feet per resident in multiple resident bedrooms. During an observation, it was noted that Resident 4's space was encroached upon by Resident 2's belongings, reducing Resident 4's livable space to 48.44 square feet. This situation was confirmed by the Maintenance Director, who acknowledged the deficiency in space allocation. Resident 2, who shared the room with Resident 4, was cognitively intact and required only setup or clean-up and supervision for activities of daily living. The room measured 164.47 square feet in total, which should have provided each resident with 82.24 square feet of space. However, due to the clutter from Resident 2's belongings, Resident 4's space was compromised. The Facility Administrator confirmed the clutter and acknowledged the potential impact on privacy, dignity, and safety. The facility's policy on providing a homelike environment was not adhered to, as the environment was not orderly or adequately accommodating for Resident 4.
Failure to Address Ceiling Leak Poses Fall Risk
Penalty
Summary
The facility failed to maintain a safe environment for residents by not addressing a persistent water leak in the ceiling of a room occupied by two residents. Resident 2, who was cognitively intact and independent in activities of daily living, and Resident 3, who had moderate cognitive impairment and required assistance for daily activities, were both at risk due to the water leak. The leak, which had been ongoing for two days, resulted in water dripping onto Resident 3's bed and accumulating on the floor, creating a potential fall hazard. Interviews with staff revealed that the ceiling had been repaired multiple times without success, and the water leak persisted whenever it rained. Despite the known risk, the residents were not moved to another room, and only temporary measures such as placing buckets to catch the water were implemented. Staff acknowledged the safety hazard posed by the wet floor, which could lead to falls and injuries. The facility's policy emphasized the importance of maintaining an environment free from accident hazards, yet the issue remained unresolved, putting the residents at risk.
Facility Fails to Address Ceiling Leaks and Thermostat Malfunction
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, staff, and the public by not addressing water leaks in the ceiling of a room occupied by two residents. Resident 2, who is cognitively intact and independent in activities of daily living, and Resident 3, who has moderately impaired decision-making skills and requires assistance with daily activities, were affected by the leaking ceiling. The ceiling above Resident 3's bed was observed to be leaking, with water dripping onto the bed and accumulating on the floor, creating a potential safety hazard. Despite the issue being reported, the residents were not moved to another room, and the problem persisted due to unsuccessful repair attempts. Additionally, the facility did not ensure that all thermostats were in safe operating condition. One of the thermostats was reported to be malfunctioning, affecting the temperature control in multiple rooms, including the Director of Nursing's office. The Maintenance Director acknowledged the issue, indicating possible electrical or mechanical failure, which could compromise residents' health and comfort. The facility's policy requires the maintenance department to keep the building and equipment in safe and operable condition, which was not adhered to in this instance.
Elevator Malfunction Poses Risk in Facility
Penalty
Summary
The facility failed to ensure that the elevator was in safe working condition, which had the potential to cause harm to residents, staff, and visitors. During an observation, a Monitor Aide (MA) reported that the elevator frequently stopped functioning, requiring him to reset the breaker in the parking garage to restore its operation. This malfunction occurred 3-4 times during his shift, and the issue was known to the Maintenance Supervisor, Administrator, and Nursing Supervisors. A Certified Nursing Assistant (CNA) and the Director of Nursing (DON) confirmed awareness of the problem, with the CNA having been stuck in the elevator previously. The DON was in discussions with the corporate office regarding repairs. The Maintenance Assistant (MA) revealed that the elevator had been malfunctioning for at least a year, with multiple employees getting stuck daily. An urgent inspection by the elevator company had been conducted, and an invoice for repairs was provided to the Administrator. However, the elevator had not been repaired as of the report date. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping equipment safe and operable at all times, which was not adhered to in this case.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that three residents had their Advance Directives or Advance Directives Acknowledgement forms documented in their active medical records. This deficiency was identified during interviews and record reviews, which revealed that the residents were not fully informed of their right to formulate advance directives. This oversight had the potential to conflict with the residents' healthcare wishes and deny them the right to request or refuse medical care and treatment. Resident 97 was admitted with diagnoses including diabetes mellitus, hypertension, and chronic kidney disease. Despite having intact cognition and requiring partial to moderate assistance with activities of daily living, there was no advance directive noted in the resident's medical record. The Registered Nurse Supervisor confirmed the absence of the document and emphasized its importance in understanding the resident's end-of-life wishes. The Director of Nursing also stated that advance directives or declinations should be immediately accessible in residents' charts to prevent unnecessary or unwanted medical treatment. Resident 48, who was admitted with conditions such as hemiplegia, muscle wasting, and morbid obesity, had intact cognition for daily decision-making but did not have a signed advance directive in the chart. Similarly, Resident 105, with diagnoses including metabolic encephalopathy and major depressive disorder, had moderately impaired cognition and no advance directive in the clinical record. The Licensed Vocational Nurse confirmed the absence of these documents and the lack of evidence that the residents' representatives were informed about advance directives. The facility's policy required that advance directives be completed within 72 hours of admission, but this was not adhered to in these cases.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to properly store and dispose of controlled and non-controlled medications according to its policy and procedures. During an observation and interview, it was revealed that expired medications were being destroyed by two-night shift licensed nurses, contrary to the facility's policy which required the Director of Nursing (DON) to handle the destruction of narcotics. Additionally, the storage container for narcotics in the DON's office was not locked or permanently affixed, making it easily accessible and posing a risk for medication diversion. The DON described the process for narcotics disposition, which involved counting by two licensed nurses before removal from medication carts, followed by storage in the DON's office until a pharmacist could waste the medication. However, the facility lacked a log or record of the dates, times, and contact information for the pharmacist or the company responsible for picking up the controlled medications. The facility's policy required that all destruction logs be maintained at the facility for at least three years, but this was not being followed, leading to a lack of accountability for these medications.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. A cell phone and personal speaker were found on the preparation sink, which is an area designated for food preparation. The individual responsible for these items acknowledged that personal items should not be in the kitchen area due to infection control concerns. Additionally, opened bags of hashbrowns in the kitchen's chest freezer were not labeled with an open date, and the Dietary Services Supervisor confirmed that the date the hashbrowns were opened was unknown. This lack of labeling could lead to the use of expired foods. Furthermore, a Dietary Aide was observed loading dirty pots and pans into the dish machine and then handling clean and sanitized dishes without washing hands between these actions. The Dietary Aide admitted to not washing hands and recognized the importance of doing so to prevent cross-contamination. The Director of Nursing emphasized the necessity of labeling food with open dates to ensure residents do not receive expired foods. The facility's policy on sanitization and refrigerated storage procedures were reviewed, indicating the need for maintaining cleanliness and proper labeling of food items.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to ensure that all essential equipment was in working order, specifically an industrial washing machine used for washing facility linen. During observations, it was noted that one of the two industrial washing machines in the laundry room was not operational, displaying an error message. Interviews with the Assistant Maintenance Supervisor (AMS) and Assistant Laundry Supervisor (ALS) revealed that the machine had been out of service for about a month due to a missing part that needed to be ordered and installed. The AMS was not familiar with the installation process, and no technician had been scheduled to perform the repair. The Director of Nursing (DON) was unaware of the status of the part order or repair appointment, acknowledging that the lack of a second machine could delay the delivery of clean linen to residents. This deficiency had the potential to significantly delay the provision of clean and sanitary linen for all 111 medically compromised residents, potentially causing frustration among residents due to delays in having their linen changed. The facility's policy required maintenance to ensure all equipment was operable, but this was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from two residents, Resident 50 and Resident 84, before initiating treatment with psychotropic medications. Resident 50, who was diagnosed with schizophrenia, major depressive disorder, gout, chronic kidney disease, and type II diabetes, had a history and physical indicating the capacity to make decisions. However, the Minimum Data Set (MDS) showed moderate cognitive impairment. Consent for medications such as Mirtazapine and Divalproex Sodium was obtained without the resident's signature, and the nurse's verification signature was unidentifiable. The physician's signature was also missing for Mirtazapine. Similarly, Resident 84, diagnosed with osteoarthritis, chronic kidney disease, major depressive disorder, anxiety disorder, hypertensive heart disease, and diabetes mellitus, had intact cognition according to the MDS. Consent for medications like Sertraline and Trazadone was obtained without the resident's signature, and the nurse's verification was missing. The facility's policy requires informed consent to be signed by the resident or their representative and verified by a healthcare professional, which was not adhered to in these cases.
Failure to Provide Homelike Environment Due to Lack of Bed Linen
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for one resident, resulting in the resident feeling uncomfortably cold while resting in bed without adequate bed coverings. The resident, who was cognitively intact and required supervision and assistance with activities of daily living, was observed without a top sheet, blanket, or pillowcase. The deficiency was noted during an observation in the resident's room, where it was found that the resident had only a fitted sheet on the bed. The issue arose when a CNA removed the resident's linen in the morning to change it but did not replace it due to a lack of clean linen available on the floor. The CNA confirmed that residents should always have a top sheet, blanket, and pillowcases, but was unable to provide these due to the unavailability of linen. The Director of Nursing acknowledged that all residents have the right to a homelike environment, which includes having a fully made bed with clean linen daily. The facility's policy on providing a homelike environment emphasizes the importance of clean bed and bath linens.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, identified as Resident 96, who required extensive help due to conditions such as cerebral palsy and muscle wasting. Despite having intact cognitive skills, Resident 96 needed significant assistance with tasks like bathing, showering, toileting, and mobility. The resident reported not being changed in a timely manner by the 3-11 shift nurses, leading to prolonged periods in soiled conditions. The resident also mentioned that the Hoyer lift was reportedly broken, preventing regular showers, although later observations confirmed that the lifts were in working condition. Interviews and record reviews revealed that there was no ADL charting for Resident 96 for the month of November, which was confirmed by the Medical Record Director and the Director of Nursing. The lack of documentation and failure to provide necessary ADL care resulted in the resident feeling angry and embarrassed, with the potential for skin infections and irritation. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene and grooming, which was not adhered to in this case.
Failure in Colostomy Care Leads to Skin Excoriation
Penalty
Summary
The facility failed to provide appropriate colostomy care for Resident 114, resulting in excoriation and potential risk for infection at the colostomy site. Resident 114, who was admitted with a diagnosis of colostomy malfunction, was observed to have a reddened and macerated colostomy site. The resident reported that the colostomy bag was not being changed as needed, sometimes going an entire day without a change, which contributed to the skin irritation. The Licensed Vocational Nurse (LVN) confirmed the resident's account and acknowledged that neglecting timely colostomy bag changes could lead to redness, infection, and skin breakdown. The Treatment Nurse (TN) corroborated that the colostomy was supposed to be changed daily and as needed, emphasizing that failure to do so could result in skin breakdown, pain, and infection. The facility's policy on Colostomy/Ileostomy Care, revised in 2010, was intended to prevent exposure of the resident's skin to fecal matter, yet the policy was not adhered to in this case. The Minimum Data Set (MDS) indicated that Resident 114 was cognitively intact and required assistance with Activities of Daily Living (ADLs), highlighting the need for staff to provide the necessary care and attention to prevent such deficiencies.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-hemodialysis assessment for a resident, identified as Resident 88, who required dialysis services due to end-stage renal disease (ESRD) and diabetes. The resident was admitted to the facility with a diagnosis of ESRD and was dependent on hemodialysis, which was scheduled for Tuesdays, Thursdays, and Saturdays. The physician's orders required the facility staff to monitor the resident's left AV shunt for bruit and thrill daily and to remove the AV fistula shunt dressing four to six hours after dialysis treatment. The facility's dialysis care plan included monitoring vital signs and reporting any signs of infection at the access site. However, the facility's dialysis communication forms lacked post-dialysis assessments on multiple occasions, specifically on 8/12/2024, 9/17/2024, 10/1/2024, 11/12/2024, 12/17/2024, and 12/30/2024. The Registered Nurse Supervisor (RNS 2) confirmed that the post-dialysis assessments were not completed as required, and there were no progress notes documenting these assessments in the resident's electronic health record. The Director of Nursing (DON) acknowledged that the dialysis communication form was intended to monitor the resident's vital signs before and after dialysis, and failing to assess the resident upon return from dialysis could result in the facility not addressing changes in the resident's health condition. The facility's policy on Hemodialysis Access Care required documentation of the catheter location, dressing condition, dialysis occurrence, and post-dialysis observations, which were not adhered to in this case.
Failure to Retrieve Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure that the social service designee followed up with the sending facility regarding a resident's personal belongings. This deficiency involved a resident who was originally admitted with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, muscle wasting and atrophy, hyperlipidemia, hypertension, and morbid obesity. The resident was capable of making her needs known but could not make medical decisions. Despite having intact cognition for daily decision-making, the resident expressed frustration over the lack of assistance in retrieving her personal belongings from the previous skilled nursing facility. During an interview, the social service designee admitted to contacting the previous facility but was unable to provide specific details or documentation regarding the transfer of the resident's belongings. The facility's policy on social services, which includes assisting residents in maintaining their highest practicable well-being and coordinating resources to meet their needs, was not adequately followed. This oversight had the potential for the resident's personal property to be misplaced or lost.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility staff failed to adhere to infection control measures in two specific instances. During a facility tour, a clean bedside table, clean linen, and a wheelchair were found stored in the bathroom of a resident's room. A Certified Nursing Assistant (CNA2) was unable to identify who placed these items there and acknowledged that they should not be in the bathroom due to infection control concerns. The Director of Nursing (DON) confirmed that such items should not be stored in bathrooms as they can become contaminated, posing an infection control risk to residents. In another instance, a Licensed Vocational Nurse (LVN 5) was observed exiting a resident's room while wearing gloves and holding a topical medication cream in the hallway. LVN 5 admitted that this practice was against infection control protocols, as personal protective equipment (PPE) should be doffed and disposed of before leaving a resident's room. Additionally, LVN 5 was unaware of which resident in the room was under enhanced barrier precautions, despite a sign indicating such precautions at the room's entrance. These actions had the potential to cause cross-contamination and spread infections within the facility.
Facility Fails to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe and operable environment for Resident 68, as evidenced by the presence of a broken trim on the wall near the resident's bed, missing knobs on the closet door, and an exposed wire running from the television to the window. These issues were present when Resident 68 was admitted to the room, and the resident expressed frustration over the lack of repairs. The Maintenance Assistant confirmed the presence of these hazards and noted that the Maintenance Supervisor had recently resigned without leaving a repair list or instructions, leaving the assistant unaware of necessary repairs throughout the facility. Resident 68 was admitted with diagnoses including cerebral infarction and hyperlipidemia and was oriented to person, place, and time. The Minimum Data Set indicated that the resident had mild cognitive impairment and required extensive assistance with daily activities. The facility's policy and procedures for maintenance services, revised in 2009, state that the maintenance department is responsible for keeping the building in good repair and free from hazards, a standard that was not met in this instance.
Failure to Provide Timely Abuse Training to New Hire
Penalty
Summary
The facility failed to ensure that a staff member, identified as Sitter 1 (STR 1), received mandatory abuse training upon hire. STR 1 was hired on June 18, 2024, but did not receive the required training on abuse until December 2024, following an allegation of abuse made by a resident. This delay in training was confirmed during interviews with STR 1 and the facility's staffer responsible for preparing work schedules, who acknowledged the absence of evidence for STR 1's abuse training upon hire. The Director of Nursing (DON) confirmed that abuse in-services are intended to be completed upon hire to educate staff on identifying and preventing abuse, neglect, and exploitation. The facility's policy, reviewed in January 2024, mandates training during orientation, annually, and as needed, covering the prohibition and prevention of abuse, recognizing signs of abuse, and reporting procedures. The lack of timely training for STR 1 potentially delayed the identification or protection of residents from possible abuse, neglect, and exploitation.
Failure to Document Medication Administration for Hypertensive Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of clonidine for hypertension. The resident, who was admitted with diagnoses including hypertensive heart disease, was prescribed clonidine 0.1 mg to be given orally every six hours as needed for systolic blood pressure (SBP) over 160 or diastolic blood pressure (DBP) over 100. However, on three occasions, the medication was not documented as administered despite the resident's SBP exceeding 160. The Licensed Vocational Nurse (LVN) involved stated that she remembered administering the medication but failed to document it in the Medication Administration Record (MAR). The resident's medical records indicated intact cognition and the capacity for medical decision-making, requiring limited assistance with daily activities. The facility's policy on medication administration required immediate documentation after administering medication, which was not adhered to in this case. This oversight placed the resident at risk for uncontrolled blood pressure, as the necessary medication was not properly documented as given during critical times.
Resident Slapped by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident who was slapped on the left cheek twice by CNA3, who then laughed at the resident. The resident, who had the capacity to understand and make decisions, reported the incident to the local police department. The resident's medical history included acute kidney failure, hyperkalemia, type 2 diabetes mellitus, benign prostatic hyperplasia, paraplegia, major depressive disorder, and anxiety disorder. The incident occurred when CNA3 entered the resident's room and was asked about the resident's discharge. After a brief exchange, CNA3 slapped the resident without warning. The resident felt violated and vulnerable, emphasizing that no resident should be subjected to such treatment. The facility staff were unaware of the incident until the police arrived with the Administrator. Interviews with other staff members, including a CNA, LVN, and RN Supervisor, confirmed that hitting a resident is considered assault and is never permissible. The facility's investigation substantiated the incident, concluding that the resident's cheek was tapped, leading to the resident calling 911. The facility's policy on abuse prevention and prohibition clearly defines physical abuse as hitting or slapping, and the facility screens potential employees for a history of abuse. Despite these measures, the incident occurred, highlighting a failure in protecting the resident from abuse by a staff member.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who had periods of confusion and was at risk due to cognitive impairments. The resident, who had a history of bipolar disorder, delirium, metabolic encephalopathy, diabetes mellitus, and acute kidney failure, was not adequately monitored or supervised. Despite being observed by a CNA near the elevator with belongings, the resident was not prevented from leaving the facility unsupervised. The resident was later found deceased in a park two days after eloping. The facility did not implement the care plan to monitor and document changes in the resident's cognitive function, nor did it have a system in place to supervise and monitor the resident's whereabouts effectively. The resident exhibited confusion, aggressive behavior, and refusal of care, but these changes were not reported to the physician. The lack of oversight and communication breakdowns contributed to the resident's ability to leave the facility without authorization. The facility's policies and procedures for wandering and elopement were not effectively followed. The resident's elopement was not immediately recognized, and the facility delayed notifying the resident's family, physician, and law enforcement. The facility's failure to have a system in place to identify significant changes in behavior and to supervise residents at risk for elopement resulted in the resident's tragic death.
Removal Plan
- All four residents currently identified as risk for elopement were reassessed for wandering/elopement by the MDS nurse.
- Monitoring of location will be documented by licensed nurses. ADLs participation will be documented by CNAs in EMR in the task section.
- The Governing Body and an interdisciplinary team revised the wandering and elopement policy, including assessment updates, risk scoring with targeted interventions, elopement drills, and procedures for missing residents.
- Reviewed and updated the change of condition policy to include procedures for assessing and notifying attending physicians of condition changes.
- Conducted a root cause analysis to identify key issues in the wandering and elopement process, including lack of oversight, communication breakdowns, inconsistent documentation, and training gaps.
- Contacted an independent consultant to review the facility's policy and procedures related to the deficient practice.
- Reviewed and updated the discharge against medical advice and out on pass policy.
- The Facility Administrator will oversee corrective actions initiated during QAPI meetings.
- The elopement/wandering binder was reviewed and will be updated by QA and/or with new admissions.
- A 24-hour receptionist and elevator monitor were hired.
- The Medical Records Department will use a monitoring tool to audit the documented frequency of routine checks/location for residents identified with a risk for wandering or elopement.
- Replaced and tested the faulty alarm on the back door and repaired the front door to ensure proper locking.
- Provided in-service training for licensed and non-licensed staff on various topics related to elopement and wandering.
Inconsistent Employment of Director of Nursing
Penalty
Summary
The facility failed to consistently employ a Director of Nursing (DON) over the past two months, which had the potential to affect resident care, clinical outcomes, and assessment. The job description for the DON position, although undated, outlines the responsibilities of planning, organizing, developing, and directing the overall operation of the Nursing Service Department in accordance with federal, state, and local standards. The Medical Records Director (MRD) confirmed during an interview that the facility has not had a consistent DON, with the last two hires quitting after three weeks and one week, respectively. There is no system in place to cover the DON's responsibilities in the interim. The facility's policy and procedures for the Director of Nursing Services, reviewed on January 25, 2024, specify that the DON should be employed full-time and is responsible for various tasks, including developing nursing service objectives, maintaining nursing policy manuals, scheduling rounds, recruiting nursing personnel, and ensuring that care is administered according to residents' assessments and care plans. The absence of a consistent DON means these critical functions may not be adequately performed, potentially impacting the quality of care provided to residents.
Failure to Maintain Comfortable Environment and Neutral Odor
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for two residents, resulting in discomfort and dissatisfaction. Resident 3 and Resident 4, both cognitively intact and requiring partial to moderate assistance with activities of daily living, reported that their room became uncomfortably cold at night, making it difficult for them to sleep. This issue was confirmed during interviews with both residents, who shared the same room. Additionally, an observation of the nursing unit revealed an ammonia-like odor, reminiscent of urine, which was confirmed by a surveyor. The facility's policy and procedures for maintaining a homelike environment emphasize the importance of a clean, sanitary, and odor-free setting, as well as maintaining comfortable temperatures between 71°F and 81°F. The failure to adhere to these standards resulted in a deficient practice that compromised the residents' quality of life.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance to a resident who was continent of bladder and bowel, leading to inadequate care. The resident, who was cognitively intact and required substantial assistance for toileting, expressed concerns during an Interdisciplinary Team meeting about not receiving timely help with toileting needs. Despite being instructed to monitor and offer toileting assistance every two hours, the resident reported that a CNA did not change her incontinence brief when requested, resulting in her brief being soaked in urine and her room having an ammonia-like smell. The CNA confirmed that the resident required two-person assistance for personal care and admitted to delaying the change of the resident's incontinence brief until another staff member was available. The Director of Nursing emphasized the importance of checking residents every two hours and changing them promptly to prevent skin issues. The facility's policy on resident rights highlighted the need for staff to respect residents' rights to cleanliness and timely care, which was not adhered to in this instance.
Failure to Provide Two-Person Assist Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance during Activities of Daily Living (ADL) care for a resident, resulting in a fall and injury. The resident, who was re-admitted to the facility with diagnoses including cerebral palsy, muscle wasting, and osteoporosis, required moderate to maximum assistance with ADL care. Despite this, on the night of the incident, a Certified Nurse Assistant (CNA) did not use a second person to assist with the resident's care, which was against the established protocol for this resident. The CNA attempted to turn the resident alone, leading to the resident falling off the bed and sustaining a sprain to her left ankle. Interviews with the resident and staff confirmed that the resident was known to require a two-person assist to prevent falls and injuries. The CNA involved admitted that the fall could have been prevented if she had called for assistance. The facility's policy on managing falls and fall risks emphasized the need for staff to identify and implement interventions to prevent falls, which was not adhered to in this case. The incident highlights a failure to follow established care protocols, resulting in harm to the resident.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to provide food consistent with the dietary preferences and allergies of a resident, specifically Resident 2, who was allergic to coconut. Despite the allergy being clearly documented in the resident's records and highlighted on the food tray card, Resident 2 was served a piece of chocolate cake containing coconut. This oversight occurred despite the resident's known allergy, which could lead to severe reactions such as throat swelling and difficulty breathing. The incident was observed during a concurrent observation and interview, where Resident 2 expressed dissatisfaction with the food service and noted that the kitchen staff was aware of her coconut allergy. The Certified Nurse Assistant (CNA) involved stated that the Licensed Vocational Nurses (LVNs) were supposed to check the food carts before the trays were distributed, but this was not done. The Registered Dietician (RD) confirmed that it was the kitchen staff's responsibility to check the food trays, and the Dietary Supervisor (DS) reiterated that the tray line staff should verify the tray cards and food trays before distribution. Interviews with various staff members, including the Registered Nurse Supervisor (RNS) and the Treatment Nurse (TN), revealed a lack of clarity regarding the responsibility for checking food trays. The facility's policy on food allergies required that allergies be noted on tray cards and other relevant documents, but this protocol was not effectively followed, leading to the resident receiving food that could potentially cause harm.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective fall prevention measures for a resident, leading to multiple falls and a serious injury. The resident, who had a history of falls and was at high risk due to conditions such as dementia, impulse control disorder, and epilepsy, experienced several falls over a period of time. Despite being identified as a high fall risk, the interventions in place were not adequately monitored or modified to prevent further incidents. The resident's care plans included measures such as placing the call light within reach, maintaining a safe environment, and encouraging the use of assistive devices, but these were not sufficient to prevent the falls. The resident's fall risk care plan was not consistently updated following each fall, and there was a lack of effective communication among staff regarding the resident's fall risk status. The facility's policy required that if falls continued despite initial interventions, additional or different interventions should be implemented. However, the resident continued to fall, and the care plans did not reflect significant changes or new strategies to address the ongoing risk. Staff interviews revealed a lack of awareness about the resident's fall history and the need for closer supervision or a sitter, which contributed to the repeated incidents. The most severe incident occurred when the resident fell and sustained a traumatic head injury, resulting in a subdural hematoma and rib fractures. This incident highlighted the inadequacy of the existing fall prevention measures and the failure to provide the necessary supervision and interventions to prevent such a serious outcome. The facility's policies on fall risk management and the use of sitters were not effectively implemented, leading to the resident's injury and subsequent hospitalization.
Incomplete Medical Records and Informed Consent Documentation
Penalty
Summary
The facility failed to ensure accurate and complete medical records for two residents, leading to deficiencies in documentation. For Resident 1, the Medication Administration Record (MAR) was found to have missing entries for various medications and dietary instructions, including Risperdal, a multivitamin, and Ortho Tri-cyclen. Additionally, there were gaps in monitoring for side effects of antipsychotic medication, schizophrenia symptoms, and pain assessments. The Assistant Director of Nursing (ADON) confirmed these documentation gaps during a review, acknowledging that without proper documentation, it is unclear if the resident received the necessary medications or services. Furthermore, Resident 1's informed consent form for Risperdal was incomplete, lacking the name, signature, and date of the medical professional who obtained the consent, as well as the verification signature of the nurse. This incomplete documentation was confirmed by the ADON, who emphasized the importance of complete documentation as proof of consent being obtained. Similarly, for Resident 3, the informed consent forms for medications Seroquel and Aripiprazole were missing the date signed by the medical professional who obtained the consent. The ADON confirmed these omissions during a review, reiterating the necessity of complete documentation. The facility's policy on charting and documentation requires that all services, progress, and changes in a resident's condition be documented accurately and completely, which was not adhered to in these cases.
Failure to Maintain Resident's Hygiene and Room Cleanliness
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming, personal hygiene, and a clean and organized environment for one resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, acute psychosis, and anxiety disorder, required moderate assistance for activities of daily living. However, the resident was observed on multiple occasions sitting on the floor next to the bed with trash and personal belongings scattered around, refusing to get back into bed and becoming aggressive when staff attempted to assist. Interviews with facility staff revealed that the resident was non-compliant with care and resisted efforts to clean the room, often yelling and screaming at staff. The Assistant Director of Nursing confirmed that there was no care plan in place to address the resident's noncompliance, acknowledging that the unclean and disorganized room posed a safety issue. The facility's policy on providing a safe, clean, and homelike environment was not adhered to, as evidenced by the resident's living conditions.
Failure to Adhere to Blood Sugar Monitoring and Insulin Administration Protocols
Penalty
Summary
The facility failed to provide care, services, and advocacy for eight residents as per professional standards of practice when the residents experienced a change in condition. Specifically, the facility did not check blood sugar levels before meals and administered insulin late or not at all. This failure was observed in multiple instances across several residents, leading to potential risks of unmanaged blood glucose levels and associated complications. For example, Resident 1 had blood sugar levels checked hours after the scheduled time, and insulin was administered late without notifying the physician. Similar patterns were observed with Residents 2 through 8, where blood sugar checks and insulin administration were consistently delayed or missed, and physicians were not informed of these deviations from the prescribed care plan. The report highlights that Resident 1, who had severe cognitive impairment and required substantial assistance for activities of daily living, had blood sugar levels checked significantly later than scheduled on multiple occasions. This resident's care plan indicated a goal of keeping blood sugar levels between 65-115 mg/dl, but the facility failed to adhere to this plan. Similar issues were noted for Resident 2, who had moderate cognitive impairment and required substantial assistance for daily activities. Resident 2's blood sugar levels were checked late, and insulin was administered based on these delayed readings without notifying the physician. Further, the report details that Resident 3, who had severe cognitive impairment and required maximum assistance, also experienced late blood sugar checks and insulin administration. The facility's failure to follow the prescribed care plans and notify physicians of these deviations was consistent across all eight residents. Interviews with staff revealed that late shift starts and inadequate coverage contributed to these deficiencies. The facility's policies and procedures for insulin administration and medication timing were not followed, leading to potential risks for the residents involved.
Failure to Maintain Staff Competencies and Certifications
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, which could potentially compromise resident safety. Specifically, one of the six sampled staff members, a Minimum Data Set Nurse (MDS1), did not have an updated Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) certification. Additionally, two Licensed Vocational Nurses (LVN2 and LVN9) were found to be missing skills check competencies. These deficiencies were identified during a concurrent interview and record review with the Director of Staff Development (DSD), who acknowledged that staff files should be updated, especially regarding BLS/CPR and skills check competencies. The facility's policy and procedures (P&P) require that licensed nurses participate in a competency-based staff development and training program and demonstrate specific competencies and skills necessary to care for residents. The P&P also mandate that key clinical staff members, including non-licensed personnel, obtain and maintain BLS/CPR certification. The failure to adhere to these policies and procedures was confirmed by the DSD, who stated that skills checks must be conducted upon hire, annually, and as needed. This lapse in maintaining and updating essential certifications and competencies had the potential to place residents at risk of not receiving proper immediate care during life-threatening situations.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the attending physician and psychiatrist when a resident experienced increased paranoia and refused prescribed medications, including Risperdal and Keppra. The resident expressed delusional beliefs of being poisoned and refused medication multiple times, which was not communicated to the medical professionals as required by the facility's policies. This lack of communication resulted in the resident's physician being unaware of the resident's condition, delaying potential necessary interventions. Additionally, the facility did not notify the physician regarding the resident's last Keppra blood level after the resident experienced a seizure. The resident was later hospitalized, and tests revealed that the Keppra level was below the therapeutic range. This oversight placed the resident at risk for further seizures and associated complications, as the physician was not informed to adjust the treatment plan accordingly. The facility's documentation practices were also deficient, with multiple instances of blank entries in the Medication Administration Record (MAR) for both Keppra and Risperdal, as well as inadequate documentation of seizure monitoring and paranoia episodes. These documentation lapses contributed to the failure to notify the physician of significant changes in the resident's condition, further compromising the resident's care and safety.
Removal Plan
- Medical Director, who was also the R1's Medical Doctor (MD 1) was made aware by the nurses regarding R1's history of refusal of Risperdal and Keppra medication.
- R1 has been taking medications: Keppra and Risperdal.
- There are no refusals noted at this time for all 10 residents receiving Keppra and six residents receiving Risperdal.
- The Director of Nursing Services informed the psychiatrist regarding the history of refusals of prescribed medication: Risperdal for R1.
- The Nurse Health Practitioner 1 (NP 1) was made aware of the R1'S blood Keppra Level and have ordered to have a repeat of blood Keppra Level.
- Keppra level was within normal range of 29.9 microgram/ml; normal range is 6 - 46 ug/ml and made aware MD 1.
- Keppra level was obtained from MD 1 by the ADON to all 10 residents on Keppra medications.
- The NP 1 seen R1 and was agreeable with the plan of care.
- Licensed nurse updated the Care Plan for history of refusal of medication of R1.
- Licensed nurse has informed NP 1 history of R1's refusal of medications and documented in the clinical record of R1.
- There are no refusal noted at this time for all 10 residents receiving Keppra.
- Licensed nurses will initiate change of condition (COC) if resident will have any refusal on medications and will notify the health practitioner. R1 has no episode of further refusal.
- Licensed Nurses were provided in-services by the facility nurse leaders with regards to and not limited to the following: initiating COC for refusal of medications, missed doses, notifying health practitioners of the refusal to medications, monitoring resident's episode of refusal to medications every shift, monitoring of episodes of behaviors such as paranoia and aggressive behaviors. 85% of licensed nurses was provided education by the DON/designee. The facility's nurse leader/designee will continue to provide in-services to all remaining nurses (15%) on their next work schedule. The Director of Staff Developer (DSD) followed up regarding implementation of the in-services and conducted skilled competency training to 85% of licensed nurses (remaining 15% of licensed nurses will be trained on skills competency upon upcoming shifts).
- The Comprehensive and personalized care plan for R1 for fall management is developed and revised by the DON and coordinated to the staff for continuity of care.
- Care plan for fall management is updated by the DON and collaborated with staff for continuity of care and implementation of the plan of care.
- Licensed nurse updated the R1 care plan for seizure management and seizure activity. Nurses will continue to document seizure monitoring in the MAR every shift as ordered.
- All 10 residents on Keppra medication have orders for monitoring for seizure every shift by their primary physicians. The licensed nurses will inform the primary physicians regarding seizure activity and re-education provided by the DON regarding sign and symptoms of seizure.
- Quality Assurance and Performance Improvement (QAPI) meeting was conducted with Medical Director, ADM, DON, Administrative personnel and ADON regarding concerns with IJ: Physician notification, informed consents, COC-episode of refusals, MAR missing documentations and manifested behaviors, seizure and fall management and precautions; the DON will continue to monitor twice a week for four weeks then once a month then quarterly and ensure the audits done in timely manner.
Failure to Administer and Monitor Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident diagnosed with schizophrenia received Risperdal as prescribed by the attending physician. The resident was refusing to take the medication and exhibited increased paranoia, including fears of being poisoned and hearing voices. Despite these symptoms, the attending physician was not informed of the resident's refusal to take the medication, nor was the pharmacist conducting a monthly medication regimen review for the resident's use of Risperdal. The facility also did not perform a gradual dose reduction for the resident's Risperdal use, which should have been conducted quarterly. The lack of communication and monitoring led to the resident's continued paranoia and eventual refusal of the medication, resulting in the resident being transferred to a general acute care hospital due to an altered level of consciousness. The facility's policies and procedures were not followed, as the resident's refusal of medication was not documented or communicated to the attending physician. The facility's failure to adhere to its policies regarding medication administration and change in a resident's condition contributed to the resident's unmanaged schizophrenia and subsequent hospitalization.
Removal Plan
- R1 received the Risperdal medication as ordered by the physician.
- The Medical Director who was also R1's primary physician was made aware by the nurses on R1's history of refusal of Risperdal medication.
- R1's informed consent for Risperdal was updated by the Nurse Practitioner 2 (NP 2) upon patient's re-evaluation. Informed consent is verified by the nurse during NP 2's visit.
- Licensed nurses provided education regarding Informed Consent by the DON.
- R1 has been taking R1's Risperdal medication. The health practitioner was made aware by the nurses on R1's history of refusal of Risperdal medication.
- Resident 1's refusal of medication is being monitored by the licensed nurses every shift along with an order to inform the practitioner for any refusal and/or missed doses.
- The medical records designee will conduct daily audits and findings will be reported to the DON for immediate action.
- Licensed nurses were provided in-services by the facility nurse leaders with regards to and not limited to the following: initiating change of condition (COC) for refusal of medications, missed doses, notifying health practitioners of the refusal to medications, monitoring resident's episode of refusal to medications every shift, monitoring of episodes of behaviors such as paranoia and aggressive behaviors.
- 85 percent of licensed nurses was provided education by the DON/designee. The facility's nurse leader/designee will continue to provide in-services to all remaining nurses on their next work schedule.
- The Director of Staff Developer (DSD) followed up regarding implementation of the in-services and conducted skilled competency training to 85% of licensed nurses (remaining 15% of licensed nurses will be trained on skills competency upon upcoming shift).
- NP2 came to the facility and was made aware by the licensed nurse of R1's paranoia episodes. NP 2 re-evaluated the resident and updated R1's behavior manifestations.
- Licensed nurses updated R1's manifestations monitoring in the Medication Administration Record (MAR).
- R1'S MRR for Risperdal was done by the Pharm1 and evaluated by NP2.
- R1's Risperdal medication was reviewed by the Interdisciplinary Team (IDT) with NP 2. At this time, per NP 2 and IDT, GDR is not warranted and to continue the current dose for Risperdal.
- Licensed nurses will initiate COC if a resident has any refusal episode and will notify the health practitioner.
- The Director of Nursing Services informed MD1 regarding the following refusals of prescribed medications: Risperdal for R1.
- 85% of all licensed nurses were provided education by the DON/designee on continuously documenting refusals and notifying the MDs on any refusals in the residents' records. The facility's nurse leader/designee will continue to provide in-service to all remaining nurses who were not educated at this time during their next work schedule.
- The DSD will follow up on competency skills check and implementation of the in-services and training.
- IDT spoke with R1 regarding his refusal, fall precaution, seizure precaution, and was educated about the risk of non-compliance, resident verbalized understanding. Next IDT meeting will be conducted.
- Quality Assurance and Performance Improvement (QAPI) was conducted with Medical Director, ADM, DON, Administrative personnel, and ADON regarding concerns with IJ: MD notification, informed consents, Change of Condition-episode of refusals, MAR missing documentations and manifested behaviors, seizure and fall management and precautions.
- DON will continue to monitor twice a week for four weeks then once a month then quarterly and ensure the audits done in timely manner.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to meet professional standards of quality care by not ensuring that documentation was completed after the administration of medications to residents. This deficiency was observed during a medication pass where a Licensed Vocational Nurse (LVN) administered medications to four residents but did not document the administration in the Medication Administration Record (MAR) immediately after each resident's medication pass. The LVN stated that she would document after administering medications to multiple residents, depending on how busy she was, which deviated from the facility's policy. The residents involved had various medical conditions, including epilepsy, schizophrenia, respiratory failure, dysphagia, chronic kidney disease, diabetes mellitus, end-stage renal disease, encephalopathy, muscle wasting, and hyperlipidemia. The Assistant Director of Nursing (ADON) confirmed that documentation should occur right after each medication pass, as failing to do so could put residents at risk of medication errors. The facility's policy required the individual administering the medication to initial the MAR after giving each medication and before administering the next ones.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident received Risperdal as prescribed by the attending physician. The resident, who was admitted with diagnoses including acute psychosis and anxiety disorder, was documented as having difficulty in new situations and required moderate assistance for activities of daily living. The resident exhibited verbal behavioral symptoms such as threatening and cursing others. Despite the physician's orders for Risperdal to be administered twice daily, the medication was not given on multiple occasions, as indicated by the Medication Administration Record. The resident's care plan did not include interventions for non-compliance with medications, and there was no documentation that the attending physician was informed of the resident's refusal to take Risperdal or the episodes of psychosis. The resident was observed sitting on the floor, refusing to get back into bed, and yelling and threatening staff. The Assistant Director of Nursing confirmed that there was no documented evidence of the physician being notified about the resident's non-compliance or psychosis episodes. The facility's policy on Behavioral Assessment, Intervention, and Monitoring was not followed, as the nursing staff failed to document and inform the physician about changes in the resident's mental status and behavior. Additionally, the policy on Requesting, Refusing, and/or Discontinuing Care or Treatment was not adhered to, as there was no evidence of staff meeting with the resident to address concerns or discuss alternative options when the resident refused treatment.
Infection Control Lapse with Foley Catheter Management
Penalty
Summary
The facility failed to observe proper infection control measures for a resident with an indwelling catheter. The resident, who was admitted with conditions including congestive heart failure, type 2 diabetes mellitus, muscle wasting, and benign prostatic hyperplasia, was observed wheeling himself in a wheelchair with his Foley catheter bag dragging on the floor. This observation was made as the resident passed by the nursing station where several staff members, including a Licensed Vocational Nurse, a Certified Nursing Assistant, and the Assistant Director of Nursing, were present, yet none intervened. The resident's care plan indicated a high risk for developing urinary tract infections due to the use of a Foley catheter, with a goal to remain free from signs and symptoms of infection. The facility's policy on catheter care emphasized maintaining a clean technique and ensuring the catheter tubing and drainage bag are kept off the floor. Despite these guidelines, the catheter bag was not properly managed, leading to a potential risk of contamination and infection, as noted by the Assistant Director of Nursing upon later intervention.
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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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