North Long Beach Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 260 E Market St, Long Beach, California 90805
- CMS Provider Number
- 055995
- Inspections on file
- 38
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at North Long Beach Post Acute during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and a history of paranoid schizophrenia, who required supervision for ambulation and sit-to-stand activities, independently entered the activity room where a CNA was assisting another resident. A rolling stool with swivel casters had been left in the room, and while the CNA briefly turned away, the resident attempted to sit on the stool, which rolled out from under them, causing a fall onto their side. The resident reported hip and rib pain and was transferred to a GACH, where multiple right rib fractures were identified. The unattended rolling stool in the dining/activity room posed a safety hazard to this and other residents.
A resident with dementia and severely impaired cognition was seen by a podiatrist despite the responsible party's prior request to remove the resident from the podiatry list. The request was communicated to both the SSD and DON, but due to lack of coordination and oversight, the resident continued to receive podiatry services against the responsible party's wishes.
A resident with severe cognitive impairment experienced a fall and was found by a CNA. The LVN on duty delayed notifying the resident's Responsible Party (RP) for approximately two and a half hours, contrary to facility policy requiring immediate notification after such incidents. The DON confirmed the delay and stated that the RP should have been informed at the time of the event.
Two residents with significant physical and cognitive impairments were found with their call lights on the floor and out of reach while in bed, despite facility policy requiring call lights to be accessible. One resident was calling out for help when observed, and the DON had to return the call lights to within reach for both residents.
A deficiency was cited for failing to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report notes that the facility did not ensure adequate safeguards were in place to prevent such mistreatment.
A resident with severe cognitive impairment and multiple diagnoses, including hypernatremia and acute kidney failure, was not monitored for fluid intake as required by their care plan. Staff did not document or track the resident's fluid consumption, despite the resident's inability to drink independently and the facility's policy mandating intake monitoring for those at risk of dehydration. This led to the resident's readmission to a hospital with severe dehydration.
Multiple food items, including juice, applesauce, cottage cheese, and dry beans, were found without required open or prepared dates, and staff failed to consistently monitor dishwasher sanitation. Additionally, a staff member was observed wearing bracelets while preparing pudding, contrary to facility policy. These actions did not meet professional standards for food storage and preparation.
Staff did not change isolation gowns between providing direct care to two residents on Enhanced Barrier Precautions, and failed to sanitize a mechanical lift between use with two residents. Both deficiencies involved residents with significant medical needs and dependency, and staff acknowledged that proper infection control protocols were not followed as required by facility policy.
Two residents with cognitive impairment were affected by failures in psychotropic medication management: one was allowed to sign informed consent for antipsychotic and antidepressant medications despite lacking capacity, and another received a PRN clonazepam order without a required stop date or documented rationale for continuation beyond 14 days, contrary to facility policy and regulatory standards.
The facility failed to accurately document MDS assessments for three residents, including not recording hemodialysis status for a resident with ESRD, incorrectly listing a discharge destination for another resident, and omitting oxygen therapy and suctioning for a resident with Alzheimer's disease. These inaccuracies were confirmed by staff and did not reflect the actual care provided.
Two residents prescribed psychotropic medications did not have individualized care plans addressing their medication use. One resident with dementia and behavioral disturbances was taking Divalproex without a corresponding care plan, and another with bipolar disorder and severe cognitive impairment was prescribed Quetiapine Fumarate (Seroquel) without a care plan. Both the LVN and DON confirmed the absence of these care plans, despite facility policy requiring comprehensive care planning for all diagnoses and medications.
A nurse administered a controlled pain medication outside of prescribed pain parameters to a resident, and there were multiple instances of inaccurate documentation for a controlled anti-anxiety medication. Additionally, two medication carts contained unsecured containers of discarded medications, contrary to facility policy. These actions and inactions resulted in deficiencies related to medication administration, documentation, and disposal.
A resident with severe cognitive impairment and lacking decision-making capacity received vaccines based on consent from the IDT, rather than from the responsible party, despite the responsible party's information being available in the admission records. Staff interviews and record review confirmed that facility policy requires the responsible party to provide consent in such cases.
A resident with Parkinson's disease, impaired cognition, and limited arm mobility was unable to access the call light, which had been left out of reach by a CNA. The resident was unable to request assistance after spilling food and needing help, and both the CNA and DON confirmed the call light should have been accessible according to facility policy.
A resident with diabetes and other complex conditions experienced multiple episodes of critically high blood sugar, as documented in the MAR. Despite physician orders and facility policy requiring immediate MD notification for blood sugar levels over 400 mg/dL, staff did not notify the MD or document a change of condition. Interviews with the MDS Coordinator and DON confirmed that required notifications and documentation were not completed.
A resident with end stage renal disease who was cognitively intact and required assistance with daily activities was transferred to a hospital, but did not receive the required written 7-day bed hold notice. Staff interviews and record reviews confirmed the absence of this documentation, which is mandated by facility policy to inform residents of their right to have their bed held during absences.
A nurse crushed a delayed release divalproex tablet and a lorazepam tablet, mixed them together, and administered the mixture to a resident with dysphagia, despite physician orders and facility policy requiring the medications to be given whole and separately. The nurse later acknowledged the error, and the DON confirmed that the medications should not have been crushed or combined.
A resident with impaired mobility and cognition was left to eat lunch while lying down, contrary to facility policy requiring upright positioning to prevent choking. In a separate incident, another resident dependent on staff for transfers was moved using a mechanical lift by only one CNA, despite the care plan and policy mandating two-person assistance. Both deficiencies were confirmed through observation, staff interviews, and policy review.
A resident with PTSD and dementia was not provided a completed trauma informed care assessment after declining to answer upon admission, and no reassessment was documented. As a result, the facility did not identify the resident's PTSD triggers or include trigger-specific interventions in the care plan, contrary to facility policy.
A resident with dementia and anxiety received PRN clonazepam without a specified duration or stop date, as required by facility policy. The consultant pharmacist and facility staff did not identify or report this irregularity during monthly medication regimen reviews, resulting in the medication being administered beyond the recommended timeframe.
A resident with atrial fibrillation and other health conditions did not receive a scheduled dose of Eliquis, and required monitoring for side effects was not documented for one shift. Staff interviews confirmed that medication administration and monitoring were not completed as ordered, in violation of physician orders and facility policy.
Two residents experienced medication administration errors when an LVN crushed and combined a delayed release divalproex tablet with lorazepam, and administered hydrocodone-acetaminophen outside of prescribed pain parameters for another resident. These actions led to a medication error rate of 11.11%, surpassing the acceptable 5% threshold.
A nurse administered hydrocodone-acetaminophen, which was prescribed only for severe pain, to a resident experiencing moderate pain on multiple occasions. Despite clear physician orders specifying the medication was for severe pain (pain level 8-10), the medication was given for pain levels as low as 4. The resident had chronic pain conditions and required assistance with daily activities. Staff interviews and record reviews confirmed that the medication was not administered according to the prescribed parameters.
Surveyors found that discontinued controlled substances and other medications were not removed or disposed of according to facility policy, with some stored improperly in a medication room refrigerator and others left accessible in unsealed biohazard containers in medication carts. Nursing staff and the DON confirmed these practices did not follow established procedures, resulting in unclean and unsecure medication storage environments.
Two residents with significant medical and functional needs did not receive PT, OT, or ST evaluations as ordered by their physicians. Instead, one resident received no evaluations, and another received only a limited rehab screen rather than a full ST evaluation. Facility staff confirmed that the required evaluations were not completed, despite policies and job descriptions mandating prompt response to physician orders.
The facility failed to maintain accurate and complete medical records for two residents. One resident's record contained conflicting active physician orders regarding weight-bearing status, leading to staff confusion. Another resident's restorative nursing services were not properly documented, with missing details on the frequency, duration, and specifics of care provided. Staff interviews confirmed the documentation issues and the facility's policy required complete and accurate records.
The QAA Committee did not identify or implement corrective actions for ongoing systemic issues, including staff failure to notify physicians of changes in resident conditions and inaccuracies in MDS assessments, as confirmed by the Administrator and policy review. These deficiencies affected all residents in the facility.
The facility did not provide or document COVID-19 vaccination education or offers to six of seven sampled employees, as required by its policy. The IPN confirmed that verbal declinations were accepted and no declination forms or documentation of education were maintained for the 2024-2025 season. The DON stated that staff should acknowledge education and refusal in writing, but this was not done.
The facility did not notify the physician in a timely manner when two residents experienced significant changes in condition, including a transfer to a hospital for breathing difficulty and new symptoms such as skin redness, agitation, and confusion. Documentation and staff interviews confirmed that required physician notification and follow-up were not completed as per facility policy.
A resident with severe cognitive impairment and behavioral challenges was physically restrained by staff using a bed sheet tied around the legs without prior assessment, physician notification, or a care plan. Less restrictive interventions were not attempted, and the restraint was applied in violation of facility policy. The incident was later discovered and reported by other staff members.
The facility failed to obtain informed consent before administering Ativan to a resident with severe cognitive impairment and did not properly monitor or document behaviors for the use of Ativan and Seroquel in two residents with significant cognitive and psychiatric conditions. Required behavioral monitoring and documentation were not completed as per facility policy, and informed consent was not verified prior to medication administration.
A resident with severe cognitive impairment and multiple fall risk factors was not provided with a fall risk care plan or interventions upon admission, despite facility policy requiring such measures. The lack of a timely care plan resulted in the resident experiencing a fall and sustaining a skin tear before appropriate interventions were implemented.
A resident was not readmitted to the facility after hospitalization due to concerns about an active C. diff infection, despite the hospital's determination that the resident was ready for transfer. The facility's DON and AD did not verify if the resident had symptoms of diarrhea, and the ADM was unaware of the policy allowing removal from isolation after 48 hours without symptoms. This led to the resident remaining in the hospital for 20 days.
A resident with severe cognitive impairment and schizophrenia punched another resident in the stomach, despite the facility's policy against abuse. The incident was witnessed by an LVN, and the DON acknowledged a lack of thorough behavior analysis for the aggressive resident.
A resident with a history of mental health disorders engaged in a verbal altercation with a CNA, who responded disrespectfully, failing to maintain the resident's dignity. Despite the resident's known behavior issues and a care plan in place, the CNA escalated the situation by speaking loudly, contrary to the facility's policy on respectful communication.
A facility failed to document a resident's refusal of psychiatric care, despite the resident being cognitively intact and having the capacity to make medical decisions. The resident's refusal of a psychiatric NP's visit was not recorded in the progress notes, as confirmed by the DON and LVN. The Social Service Director was aware of the refusal but did not document it, contrary to the facility's policy requiring timely documentation to ensure continuity of care and respect for resident rights.
A facility failed to include the responsible parties of a cognitively impaired resident in an IDT care conference following the resident's fall. Despite the resident's inability to make decisions, the RPs were not notified or involved in the meeting, which discussed the resident's care plan. This oversight violated the facility's policies and the resident's rights, leading to frustration and distrust from the RPs.
A resident with dementia and other health conditions was not tested for COVID-19 as ordered, and the facility failed to notify the resident's doctor and responsible parties. The Director of Nursing confirmed the oversight, which violated the resident's rights and altered the plan of care.
A resident with cerebral infarction and other conditions had their personal belongings inadequately safeguarded. Despite receiving a new debit card, the inventory list was not updated, and the resident's bedside drawer was left open, exposing personal items. Staff interviews revealed a lack of coordination in maintaining accurate inventories, and the resident expressed concerns about the security of their belongings due to a missing key.
A resident on Plavix, with a history of heart disease and hyperlipidemia, was not properly monitored for bruising as required by their care plan. Despite reporting an incident with a CNA that resulted in bruises, the facility failed to document or assess these changes. Staff interviews confirmed the oversight, and the DON acknowledged the failure to follow the care plan, which required monitoring for bleeding due to anticoagulant therapy.
A resident sustained a foot fracture after a housekeeper ran over her foot with an overfilled laundry cart, obstructing the housekeeper's view. The resident, previously ambulatory, became wheelchair-dependent due to the injury. The facility's policy on laundry cart usage was not followed, contributing to the accident.
The facility failed to monitor and provide necessary range of motion (ROM) exercises for two residents, leading to contractures and pain for one resident. Despite physician orders and resident requests, passive ROM exercises were not consistently performed, resulting in significant mobility limitations and pain. Additionally, the facility did not adequately assess ROM during quarterly screenings, risking further decline in residents' mobility.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident with acute respiratory failure and vascular dementia, and another with congestive heart failure and moderate cognitive impairment, were observed with call lights out of reach. Despite care plans requiring call light accessibility, this was not maintained, as confirmed by staff interviews and facility policy.
Two residents experienced significant declines in mobility and range of motion, but the facility failed to notify nursing and the physician, preventing necessary interventions. One resident had increased pain and range of motion impairments, while the other showed a decline in mobility and ADLs. Despite facility policy requiring immediate notification of changes, these were not communicated, leading to a deficiency in care.
The facility failed to update the PASARR for a resident newly diagnosed with a mental illness and did not follow recommendations for Level II evaluations for three other residents. This oversight involved residents with severe cognitive impairments and various mental health diagnoses, potentially affecting their psychiatric care. The DON acknowledged the need for PASARR II evaluations, especially for residents on psychotropic medications, but the facility did not adhere to its policy on informing residents about medication use.
A facility failed to administer Restasis for a resident with dry eye syndrome due to stock unavailability, did not document clonazepam administration for another resident, and misapplied lidocaine cream for a third resident. The DON confirmed these deficiencies, emphasizing the importance of following physician orders and maintaining accurate records.
The facility did not follow its policy on food handling and storage by failing to date prepared food stored in the refrigerator. During an observation, it was found that snacks and nourishment were not labeled with preparation or expiration dates. The Dietary Supervisor confirmed the oversight, which could potentially lead to foodborne illnesses among residents.
The facility failed to follow proper infection control measures for two residents. An AMDSC improperly doffed PPE after addressing a feeding pump issue for a resident, risking contamination. Additionally, an LVN placed a medication tray next to a urinal during administration, creating unsanitary conditions. These actions violated the facility's infection prevention protocols, potentially spreading infections.
The facility failed to implement its antibiotic stewardship program by prescribing antibiotics without meeting necessary criteria for three residents. The Infection Preventionist confirmed that McGeer's criteria were not documented as met for these residents, despite the facility's policy requiring such documentation before starting antibiotic treatment.
The facility failed to maintain updated records of COVID-19 vaccination status for staff and residents, as revealed by the Infection Preventionist Nurse (IPN) who noted the last update was in March 2024. The COVID-19 Staff Vaccine Log showed missing documentation for several staff members, and the Residents Vaccination Status Log lacked information on residents' vaccination status. The Director of Nursing (DON) confirmed the importance of offering immunizations to prevent virus spread, but the facility's policies on education and documentation were not followed.
Failure to Remove Rolling Stool Hazard Resulting in Resident Fall and Rib Fractures
Penalty
Summary
The facility failed to ensure the dining/activity room was free from accident hazards when a rolling stool with swivel casters and adjustable height was left in the area, posing a safety risk to residents. A resident with paranoid schizophrenia and moderately impaired cognition, who required supervision for walking more than 10 feet and for sit-to-stand activities, independently ambulated into the activity room where CNA 1 was present and assisting another resident. While CNA 1 briefly turned away, the resident attempted to sit on the unattended rolling stool. As the resident tried to sit, the rolling stool moved out from under her, causing her to lose balance and fall onto her left side. Following the fall, the resident complained of pain to the right hip and left rib area. An SBAR documented that the fall was unwitnessed and that the resident was found lying on her left side. The physician ordered transfer to a GACH for suspected fall with injury, and hospital records indicated the resident was assessed with multiple right rib fractures. The deficient practice had the potential to cause harm to other residents who were in the area where the rolling stool was left unattended.
Failure to Honor Responsible Party's Request for Podiatry Services
Penalty
Summary
A deficiency occurred when the facility failed to honor a responsible party's request to remove a resident from the podiatrist patient list. The resident, who had dementia and severely impaired cognition, was dependent on staff for activities of daily living. The responsible party had communicated the request to remove the resident from the podiatry list to both the Social Services Director (SSD) and the Director of Nursing (DON) during an Interdisciplinary Team meeting and through direct communication. The SSD acknowledged receiving the request in August, while the responsible party stated the request was initially made in January. Despite these communications, the resident was seen by the podiatrist after the removal request had been made. Interviews with facility staff revealed a lack of coordination between the social services department and the podiatrist's office regarding which residents were to be seen. The DON confirmed that the request to remove the resident from the podiatry list was overlooked and that proper coordination should have occurred when the request was first made. Review of facility policy indicated that residents have the right to be informed of and participate in their care planning and treatment, which was not upheld in this instance.
Delayed Notification of Responsible Party After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a resident's Responsible Party (RP) of a significant change in condition following a fall. The resident, who had dementia and was severely cognitively impaired, was found on the floor by a Certified Nurse Assistant at 4:39 a.m. The facility's records show that the RP was not notified until 7:00 a.m., resulting in an approximately two-and-a-half-hour delay. The facility's policy required immediate notification of the resident representative in the event of an accident involving the resident. Interviews revealed that the Licensed Vocational Nurse (LVN) who discovered the fall was hesitant to report the incident to the RP and required guidance from the Director of Nursing (DON) to complete post-fall procedures. The DON confirmed that the RP should have been notified at the time of the incident, in accordance with facility policy. The delay in notification was confirmed by both the RP and facility staff during interviews and record review.
Call Lights Not Accessible to Dependent Residents
Penalty
Summary
Facility staff failed to ensure that call lights were within reach for two residents who were both dependent on staff for activities of daily living. One resident had hemiplegia affecting the left side, muscle weakness, and contractures, and was assessed as having moderate cognitive impairment. The other resident had Alzheimer's disease, muscle weakness, contractures, and was severely cognitively impaired. Both residents required staff assistance for toileting, bathing, dressing, and personal hygiene. During an observation, both residents were found in their room with their call lights on the floor, out of reach, and one resident was calling out for help. The Director of Nursing entered the room, observed the call lights were not accessible, and placed them within reach. Facility policy required staff to ensure call lights were accessible to residents when in bed, but this was not followed, resulting in the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency centers on the lack of comprehensive protection for residents against abuse and neglect, as required by regulatory standards.
Failure to Monitor Fluid Intake for At-Risk Resident
Penalty
Summary
Facility staff failed to monitor and document fluid intake for a resident who was at risk for dehydration. The resident, who had diagnoses including hypernatremia, acute kidney failure, and Alzheimer's disease, required partial to moderate assistance and was identified in the care plan as being at risk for dehydration. The care plan specified monitoring for signs and symptoms of dehydration and encouraging or assisting with fluid intake. However, documentation for the months reviewed showed no entries for fluid intake, and staff interviews confirmed that there was no active task or system in place to record the resident's fluid consumption during this period. The resident was unable to eat or drink independently and required total assistance from staff, who reported that although fluids were offered, the resident often refused them. Despite this, there was no documentation of fluid intake, and the facility's policy required intake and output monitoring for residents at risk of dehydration. The deficiency resulted in the resident being readmitted to a general acute care hospital with severe dehydration and hypernatremia, as documented in the hospital's history and physical report.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and handle food in a sanitary manner, as evidenced by multiple observations and staff interviews. In the kitchen refrigerator, containers of thickened apple juice, applesauce, and cottage cheese were found without open or prepared dates. Additionally, a large container of white beans in the dry food area was not dated. Staff interviews confirmed that these items should have been labeled with open or prepared dates to ensure proper tracking and timely disposal. The facility's dietary staff acknowledged the importance of dating food items, particularly dairy products and dry goods, to prevent spoilage and ensure food safety. Further deficiencies were observed in the monitoring of the dishwasher's chemical sanitation. The dishwasher worker admitted to forgetting to check and record the sanitation fluid levels, despite the facility's policy requiring checks at least once per shift. Additionally, during food preparation, a staff member was observed wearing three bracelets while mixing pudding, with the jewelry hanging over the food. The staff member acknowledged that jewelry should not be worn during food preparation, as it poses a risk of physical contamination. The facility's policies require proper labeling, dating, and monitoring of food items, as well as restrictions on jewelry during food preparation, but these were not consistently followed.
Failure to Follow Infection Control Protocols for PPE and Equipment Cleaning
Penalty
Summary
The facility failed to maintain and observe proper infection control measures in two key areas. First, a Restorative Nursing Aide (RNA) did not change isolation gowns between providing direct, high-contact care to two different residents who were both on Enhanced Barrier Precautions (EBP). Specifically, after assisting one resident with range of motion exercises and applying splints, the RNA removed gloves and performed hand hygiene but did not change the isolation gown before repositioning another resident in the same room, both of whom were under EBP due to their medical conditions and physician orders. The RNA acknowledged during an interview that the gown should have been changed between residents to prevent cross-contamination, and both the Infection Preventionist Nurse and the Director of Nursing confirmed that facility policy and infection control protocols require changing gowns and gloves between residents on EBP. Second, the facility did not ensure that the mechanical lift used for transferring residents was sanitized between uses for different residents. Observations showed that after transferring one resident with the mechanical lift, staff did not clean the equipment before using it to transfer another resident. Interviews with the CNA involved, as well as other staff including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, confirmed that the mechanical lift should be disinfected after each resident's use to prevent possible cross-contamination. The facility's policy also requires cleaning and disinfecting resident care equipment according to CDC recommendations and OSHA standards. The residents involved in these deficiencies had significant medical conditions, including malnutrition, dysphagia, diabetes, heart failure, contractures, and severe cognitive impairment, which made them dependent on staff for most activities of daily living and placed them at increased risk for infection. The failure to follow established infection control protocols in both the use of personal protective equipment and the cleaning of shared medical equipment created a potential for the transmission of infectious microorganisms among residents and staff.
Failure to Ensure Proper Informed Consent and PRN Psychotropic Medication Documentation
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a documented inability to make medical decisions was not permitted to sign informed consent forms for psychotropic medications. Specifically, the resident, who had diagnoses including schizophrenia, unspecified intellectual disabilities, and a cognitive communication deficit, was found to have signed his own consent for both antipsychotic and antidepressant medications. The Director of Nursing confirmed that the resident did not have the capacity to provide informed consent, as indicated in the resident's history and physical, and that the consent obtained was therefore invalid. Additionally, the facility did not ensure that another resident's PRN psychotropic medication order included a specific duration or stop date, nor did it document a clinical reason for extending the order beyond 14 days. The resident, who had diagnoses of unspecified dementia, anxiety disorder, and depression, was not capable of making medical decisions. The order for clonazepam was written as PRN with an indefinite end date and lacked documentation of a specific treatment duration or rationale for continuation beyond the standard 14-day limit. Both the LVN and the consultant pharmacist acknowledged that the order should have included a stop date or specified duration, and the facility's policy required such documentation. The facility's own policy stated that PRN orders for psychotropic drugs are limited to 14 days unless the prescriber documents a rationale for extension and indicates the duration. The policy also required verification of informed consent prior to administration of psychotropic medications. In both cases, the facility failed to follow its own procedures and regulatory requirements, resulting in deficiencies related to the use and documentation of psychotropic medications.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document the Minimum Data Set (MDS) assessments for three of twelve sampled residents, resulting in discrepancies between the residents' actual care needs and what was recorded. For one resident with end stage renal disease who was dependent on hemodialysis, the MDS did not reflect their hemodialysis status, despite physician orders and medical records indicating regular dialysis treatments outside the facility. The MDS Coordinator acknowledged this miscoding and confirmed that the resident was indeed receiving hemodialysis at the time of the assessment. Another resident's discharge destination was inaccurately documented in the MDS. Although the discharge plan documentation showed the resident was discharged to the community, the MDS incorrectly indicated a discharge to an acute hospital. The MDS Coordinator confirmed this was a miscoding and emphasized the importance of accurate MDS documentation for care planning. A third resident, who had diagnoses including Alzheimer's disease and was dependent on self-care and mobility, was receiving oxygen therapy and had orders for suctioning. However, the MDS assessment did not indicate the use of oxygen therapy or suctioning, despite direct observation and physician orders confirming their use. Both the MDS Coordinator and the Director of Nursing stated that the MDS should have reflected the resident's actual care needs and services provided, and that inaccurate MDS documentation does not represent the care delivered to residents.
Failure to Develop and Implement Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including dementia, depression, and anxiety disorder, there was no care plan in place for the use of Divalproex, which was ordered to manage sudden angry outbursts related to dementia with behavioral disturbances. The resident's records indicated moderate cognitive impairment and a need for minimal assistance with activities of daily living. Both the LVN and DON confirmed during interviews and record reviews that a care plan for Divalproex was missing, and acknowledged the importance of such a plan for monitoring parameters, potential side effects, and appropriate interventions. Another resident, admitted with bipolar disorder and exhibiting restlessness and agitation, was prescribed Quetiapine Fumarate (Seroquel) for disorganized thought processes. This resident had severe cognitive impairment and was taking antipsychotic medication, but did not have a care plan addressing the use of Seroquel. The DON confirmed the absence of a care plan for this medication and stated that care plans for antipsychotic medications are necessary to monitor side effects and evaluate the effectiveness of interventions. Facility policy requires comprehensive, individualized care plans for each resident, incorporating all diagnoses and medications, but this was not followed for these two residents.
Deficiencies in Controlled Medication Administration, Documentation, and Disposal
Penalty
Summary
A deficiency occurred when a nurse administered hydrocodone-acetaminophen, a controlled medication prescribed for severe pain (pain level 8-10), to a resident who reported a pain level of 6, which is considered moderate pain. The medication was given outside the prescribed parameters on multiple occasions, as confirmed by a review of the Medication Administration Record (MAR) and interviews with the nurse and Director of Nursing (DON). The nurse acknowledged administering the medication for moderate pain and stated that physician orders should have been followed or clarified if the resident's pain level changed. Another deficiency was identified in the documentation and accountability of controlled substances. For a resident prescribed lorazepam oral concentrate, the facility's controlled drug record (CDR) did not accurately reflect the administration of the medication. The nurse admitted to administering the medication but failing to document it immediately on the CDR, which was confirmed by discrepancies between the medication container, CDR, and electronic medical record. The DON confirmed that immediate documentation is required to account for controlled medications and prevent errors. Additionally, the facility failed to ensure the proper disposal of discarded medications. Observations of two medication carts revealed red containers filled with tablets and capsules with open lids, making the medications retrievable and accessible. Nurses stated that these containers should have been emptied into the incineration bin and that leaving them accessible posed a risk for accidental exposure or misuse. Facility policy required that outdated or discarded medications be immediately removed and disposed of according to established procedures.
Failure to Obtain Informed Consent from Responsible Party for Resident Lacking Capacity
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party for the administration of vaccines to a resident with severe cognitive impairment. The resident, who had diagnoses including metabolic encephalopathy and dementia, was determined by both the History and Physical and the Minimum Data Set to lack the capacity to make medical decisions. Despite this, the facility's Interdisciplinary Team (IDT) provided consent for the pneumococcal and RSV vaccines, rather than obtaining consent from the resident's responsible party. Interviews and record reviews revealed that the responsible party's contact information was available in the hospital referral packet at the time of admission, but the facility did not utilize this information when obtaining consent. Staff confirmed that facility policy requires the responsible party to provide consent when a resident lacks decision-making capacity and has an appointed representative. The failure to involve the responsible party in the consent process resulted in the resident not being fully informed or able to exercise the right to refuse treatment as required by facility policy.
Call Light Not Accessible to Resident with Functional Limitations
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light device was within reach for one of six sampled residents. The resident, who had diagnoses including Parkinson's disease, diaphragmatic hernia, and lack of coordination, was admitted with significant functional limitations in both arms and moderately impaired cognition. The Minimum Data Set indicated the resident required substantial to maximal assistance with most activities of daily living and was dependent for bathing, dressing, and toilet hygiene. During an observation, the resident was found lying in bed, unable to reach the call light, which was placed over a foot away on an oxygen concentrator. The resident was unable to call for assistance after spilling food and needing help to clean and change clothing. A CNA confirmed that she had placed the call light out of reach earlier and forgot to return it to an accessible position. Both the CNA and the DON acknowledged that the call light should always be within the resident's reach, as per facility policy.
Failure to Notify Physician of Critically High Blood Sugar Levels
Penalty
Summary
The facility failed to notify the medical doctor (MD) when a resident experienced multiple episodes of significantly elevated blood sugar levels, as required by physician orders and facility policy. The resident, who had diagnoses including chronic kidney disease, diabetes mellitus, depression, and dementia, was admitted with a care plan that identified a high risk for hypo/hyperglycemia and required monitoring and reporting of abnormal blood sugar findings to the physician. The physician's order specifically instructed staff to call the MD immediately for blood sugar levels greater than 400 mg/dL and to document any change of condition. Record reviews revealed that the resident had several blood sugar readings over 400 mg/dL during the month, with values of 422, 451, 401, and 437 mg/dL on separate occasions. Despite these critical readings, there was no documentation in the Medication Administration Record (MAR), nurse progress notes, or change of condition assessments indicating that the MD was notified or that a change of condition was documented for any of these episodes. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that staff did not notify the MD as required and did not complete the necessary change of condition documentation. The facility's policy mandates immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this case.
Failure to Provide Written Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written 7-day bed hold notice to a resident who was transferred to a general acute care hospital. The resident, who had end stage renal disease and was dependent on renal dialysis, was cognitively intact and required varying levels of assistance with daily activities. Upon review of the resident's admission and medical records, there was no documentation confirming that the required bed hold notification was given at the time of transfer. Interviews with facility staff, including the Health Information Manager, a registered nurse, and the Director of Nursing, confirmed that the resident did not receive the written bed hold notice as required by facility policy. The policy states that all residents or their representatives must be provided with written information about bed-hold policies both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer was an emergency. The absence of this documentation constituted a failure to inform the resident of their right to have their bed held during their hospital stay.
Crushing and Co-Administration of Delayed Release and Controlled Medications
Penalty
Summary
Licensed Vocational Nurse (LVN) 1 failed to follow professional standards during medication administration for a resident with dysphagia and multiple dependencies in activities of daily living. During a medication pass, LVN 1 crushed a delayed release (DR) divalproex tablet and a lorazepam tablet, mixed the powders together, and administered them with applesauce to the resident. The physician's orders specified that divalproex DR was to be given as a whole tablet, and facility policy indicated that timed release tablets should not be crushed. The resident's medical records indicated a history of dysphagia, requiring a mechanical soft diet and thin liquids, but there was no indication that the resident was unable to swallow whole tablets. LVN 1 acknowledged after the incident that she realized the divalproex DR should not have been crushed and that the medications should have been administered separately to identify any intolerance. The Director of Nursing confirmed that both medications should have been given as whole tablets and not together in crushed form. Facility policies reviewed stated that medications must be administered as prescribed and that timed release tablets are not to be crushed. The failure to adhere to these policies and professional standards resulted in the administration of crushed delayed release medication and the mixing of two medications, contrary to physician orders and facility guidelines.
Failure to Ensure Safe Positioning During Meals and Proper Mechanical Lift Transfers
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease, diaphragmatic hernia, and limited coordination was observed eating lunch while lying in bed with the head of the bed elevated to less than 30 degrees. The resident was positioned low in the bed and slouched forward, and was unable to adjust the bed to a more upright position. The certified nursing assistant (CNA) delivered the lunch tray, confirmed the resident was lying down, and did not offer to reposition the resident to an upright position before leaving the room. The resident ate and drank in this position and began coughing. Both the speech therapist and the director of nursing confirmed that residents should be seated upright while eating to prevent choking and aspiration, and facility policy required proper positioning for meals served in bed. Another deficiency was found when a resident with severe cognitive impairment, contractures, and abnormal posture was transferred from bed to wheelchair using a mechanical lift by only one CNA, despite the care plan and facility policy requiring two-person assistance for such transfers. The CNA stated she had performed single-person transfers before when other staff were busy, acknowledging the risk of falls and injury. Other staff, including another CNA, the staff development department, and the director of nursing, all confirmed that two-person assistance is required for mechanical lift transfers to ensure resident safety. Both deficiencies were supported by direct observation, staff interviews, and review of facility policies and procedures, which clearly outlined the required standards for resident positioning during meals and for mechanical lift transfers. The actions and inactions of staff in these instances did not align with established protocols, resulting in unsafe conditions for the residents involved.
Failure to Complete Trauma Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to perform a trauma informed care assessment for a resident diagnosed with post-traumatic stress disorder (PTSD) and dementia. Upon admission, the resident's record indicated a diagnosis of PTSD, and the Minimum Data Set (MDS) confirmed severe cognitive impairment and PTSD. The Social Services Director (SSD) stated that the trauma assessment, which is typically completed upon admission for residents with trauma diagnoses, was not completed because the resident declined to answer at the time. The SSD acknowledged that if a resident declines, the assessment should be attempted again, but no reassessment was documented in the resident's chart. As a result, the facility did not identify the resident's PTSD triggers, which is necessary to provide trauma informed care and minimize the risk of re-traumatization. The facility's policy requires identification of trauma triggers and the implementation of interventions to reduce exposure to those triggers, but this was not done for the resident in question. The lack of a completed trauma assessment meant that the resident's care plan did not include trigger-specific interventions as required by facility policy.
Failure to Identify Missing Stop Date for PRN Clonazepam Order
Penalty
Summary
A deficiency occurred when the facility and its consultant pharmacist failed to identify and report that a resident was receiving clonazepam, a controlled medication, without a specified duration of treatment or a stop date. The medication order, which was written as a PRN (as needed) for anxiety-related behaviors, was initiated without a discontinuation date and continued beyond the recommended timeframe. The facility's policies required that PRN psychotropic medications have a specific duration, typically 14 days, and that any continuation beyond this period be justified by the prescriber. However, the order for clonazepam remained active without such documentation or review. Interviews with facility staff, including a Licensed Vocational Nurse, the consultant pharmacist, and the Director of Nursing, confirmed that the lack of a stop date or duration for the PRN clonazepam order was not identified during the monthly medication regimen review. The resident involved had significant cognitive and functional impairments, requiring extensive assistance with activities of daily living and was not capable of making medical decisions. The facility's policy on medication regimen review emphasized the need for comprehensive monthly reviews to prevent or minimize adverse consequences, but this process failed to detect the irregularity in the resident's medication order.
Failure to Administer and Monitor Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including atrial fibrillation, diabetes mellitus, major depressive disorder, and anemia, was not properly administered and monitored for an anticoagulant medication, Eliquis. The resident's care plan and physician orders required administration of Eliquis twice daily and monitoring for specific signs and symptoms of bleeding or adverse effects every shift. Documentation in the medication administration record (MAR) showed that on one day, the medication was not recorded as given, and required monitoring was not documented for the day shift. Interviews with nursing staff and the Director of Nursing confirmed the importance of adhering to physician orders for both medication administration and monitoring, especially for residents on blood thinners due to the high risk of bleeding. Staff acknowledged that if documentation was left blank, it indicated that the medication was not administered and monitoring was not performed as required. The facility's policy also required licensed nurses to document and implement physician orders and maintain accurate records. The failure to administer the prescribed dose of Eliquis and to document required monitoring for side effects on the specified date constituted a lapse in following physician orders and facility policy. This inaction had the potential to delay necessary care and services for the resident, as noted in the findings.
Medication Administration Errors Exceeding Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an observed error rate of 11.11%. For one resident with a diagnosis of dysphagia and schizophrenia, a Licensed Vocational Nurse (LVN) crushed a delayed release divalproex tablet and a lorazepam tablet, then mixed and administered them together with applesauce. The physician's order specified divalproex as a delayed release tablet, which should not be crushed, and the facility's policy also indicated that timed release tablets must not be crushed. The LVN acknowledged after the fact that the medication should not have been crushed and that the two medications should have been administered separately to identify any intolerance to either medication. Additionally, the same LVN administered hydrocodone-acetaminophen to another resident for pain levels that did not meet the physician's prescribed parameters. The order specified that hydrocodone-acetaminophen was to be given only for severe pain (pain level 8-10), but the medication was administered multiple times for moderate pain levels (pain levels 4-7). The Medication Administration Record (MAR) review revealed at least 15 instances over three months where the medication was given outside the prescribed pain parameters. The LVN stated that she administered the medication for a pain level of 6 because the resident was supposed to receive therapy, despite the order's requirements. Interviews with the Director of Nursing (DON) confirmed that the medications were not administered according to physician orders and facility policy. The DON stated that delayed release divalproex should not have been crushed and that hydrocodone-acetaminophen should only have been given for severe pain as ordered. Facility policy required medications to be administered as prescribed and for staff to verify the right medication, dose, and time before administration. These failures resulted in a medication error rate exceeding the regulatory threshold.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
A deficiency occurred when a nurse administered hydrocodone-acetaminophen, a controlled medication prescribed for severe pain (pain level 8-10), to a resident experiencing moderate pain (pain level 6) and on multiple occasions for pain levels below the prescribed threshold. The physician's order specifically stated that hydrocodone-acetaminophen 5-325 mg should be given every 12 hours as needed only for severe pain, and not to exceed 3 grams of acetaminophen in 24 hours. Despite this, the medication was given for pain levels ranging from 4 to 7, which did not meet the criteria for severe pain as outlined in the order. The resident involved had a history of chronic pain conditions, including generalized arthritis, low back pain, migraine, and chronic pain syndrome. The resident was cognitively intact and required assistance with activities of daily living. During medication administration, the nurse acknowledged that the resident's pain level was 6 but proceeded to administer hydrocodone-acetaminophen, citing the resident's need for therapy as a reason. Review of the Medication Administration Record (MAR) over several months revealed at least 15 instances where the medication was administered outside of the prescribed pain parameters. Interviews with nursing staff and the Director of Nursing confirmed that the medication was not given in accordance with physician orders or professional standards of practice. The facility's policy required medications to be administered as prescribed and for staff to consult the prescriber if there were concerns about dosage or appropriateness. The nurse involved recognized the importance of following pain level parameters and admitted that the order should have been clarified with the physician if the resident's pain management needs had changed.
Improper Storage and Disposal of Medications
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications in the facility. Discontinued lorazepam oral solutions, a controlled substance, for two residents were found in the medication room refrigerator, despite physician orders indicating the medications had been discontinued. These medications were not removed or disposed of according to the facility's policies, which require discontinued controlled substances to be documented and destroyed by the DON and consultant pharmacist. Additionally, other medications for one resident, including ondansetron orally disintegrating tablets, hyoscyamine sublingual tablets, acetaminophen suppositories, ipratropium with albuterol inhalation solution, and bisacodyl suppositories, were stored in the refrigerator contrary to manufacturer specifications, which could affect their safety and efficacy. Further observations revealed that two medication carts contained unsealed red biohazard containers filled with discarded tablets and capsules. The containers were left with open lids, making the medications accessible and retrievable. Nursing staff interviewed were unaware of why the containers were left in this state and acknowledged that the medications should have been removed or discarded properly to prevent accidental exposure or misuse. The DON confirmed that the red bins should have been emptied into the incineration bin and that accessible medications posed a risk for misuse and accidental exposure. Facility policies reviewed by surveyors outlined the proper procedures for the disposal of controlled and discontinued medications, as well as requirements for medication storage areas to be clean, well-lit, and free of clutter. Despite these policies, the facility failed to ensure compliance, resulting in discontinued and improperly stored medications remaining accessible in medication storage areas and medication carts.
Failure to Provide Ordered Rehabilitative Evaluations
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by physician's orders for two residents. For one resident with diagnoses including aphasia, cerebral infarction, dysphagia, and contractures, there were physician's orders for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluations. Despite these orders, the resident did not receive the required evaluations. The Director of Rehabilitation (DOR) confirmed that the evaluations were not conducted and could not provide a reason for the omission, acknowledging that the orders should have been followed. Another resident, admitted with Parkinson's disease, diaphragmatic hernia, and lack of coordination, had a physician's order for a speech therapy evaluation. Instead of a formal evaluation, the speech therapist performed a limited, hands-off rehab screen and determined that a full evaluation was not needed. Both the speech therapist and the DOR confirmed that the facility's practice was to conduct a rehab screen first, regardless of the physician's order for a formal evaluation, and only proceed with a full evaluation if the screen indicated a need. This practice resulted in the resident not receiving the ordered ST evaluation. Observations and interviews with both residents revealed significant functional limitations, including impaired cognition, limited range of motion, and difficulties with activities of daily living. Facility policy and job descriptions reviewed indicated that therapy services were to be provided upon written physician order and that therapists were responsible for promptly evaluating patients upon receiving such referrals. Despite these policies, the required evaluations were not completed as ordered for the two residents.
Failure to Maintain Accurate and Complete Medical Records and Documentation
Penalty
Summary
The facility failed to ensure the accuracy and clarity of medical records for two residents, resulting in deficiencies related to documentation and communication of care. For one resident with a history of a right femur fracture and abnormal gait, the medical record contained two active, conflicting physician's orders regarding the weight-bearing status of the right leg. One order indicated weight bearing as tolerated, while a subsequent order required non-weight bearing due to a wound on the right heel. Both orders remained active in the record, causing confusion among staff about the correct precautions to follow. Interviews with nursing and rehabilitation staff confirmed the presence of conflicting orders and acknowledged the importance of discontinuing outdated orders to prevent miscommunication and inappropriate care. Another resident, admitted with diagnoses including congestive heart failure, major depressive disorder, dementia, and post-traumatic stress disorder, was receiving Restorative Nursing Aide (RNA) services as ordered for passive range of motion, mobility exercises, and splint application. However, the documentation in the Restorative Nursing Weekly/Monthly Progress Reports was incomplete and lacked critical details such as the number of repetitions, resistance, speed, and average time spent per day on each intervention. Although RNA staff indicated that services were being provided and referenced other forms, the required documentation on the official progress reports was missing or unclear. This incomplete documentation failed to accurately reflect the services provided and could lead to gaps in care continuity. Facility policy required that all services, progress toward care plan goals, and changes in resident condition be documented objectively, completely, and accurately in the medical record. Staff interviews confirmed the expectation for clear and accurate documentation and acknowledged that incomplete records could result in an inaccurate reflection of care and services provided. The deficiencies identified were based on direct observation, record review, and staff interviews, and were consistent with the facility's own policies regarding charting and documentation.
QAA Committee Failed to Address Repeated Systemic Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and address repeated systemic problems that had been previously identified during the last survey process. Specifically, the committee did not recognize or implement corrective actions regarding staff failure to notify the medical doctor of any change in residents' conditions and the inaccuracy of the Minimum Data Set (MDS) assessments for residents. These issues were confirmed during an interview with the Administrator, who acknowledged that the QAA committee did not identify these ongoing problems during the current survey process. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the committee is responsible for developing, implementing, and maintaining a data-driven program focused on care outcomes and quality of life. The policy also states that the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities. Despite these requirements, the committee failed to detect and address the deficiencies related to physician notification and MDS accuracy, affecting all 102 residents in the facility.
Failure to Document and Educate Staff on COVID-19 Vaccination
Penalty
Summary
The facility failed to offer and educate staff on COVID-19 vaccinations in accordance with its own policy for six of seven sampled employees. During interviews and record reviews, the Infection Preventionist Nurse (IPN) confirmed that while COVID-19 vaccines and boosters are encouraged, the facility accepts verbal declinations and does not utilize vaccine declination forms or maintain documentation showing that staff were offered and educated about the COVID-19 vaccine for the 2024-2025 season. The Director of Nursing (DON) acknowledged the importance of documenting staff vaccination education and refusals, stating that there should be an employee acknowledgement form indicating education about risks, benefits, and refusal of the vaccine. Review of the facility's undated COVID-19 policy indicated that all staff are required to be fully vaccinated for COVID-19.
Failure to Notify Physician of Resident Change in Condition and Transfer
Penalty
Summary
The facility failed to notify the physician in a timely manner for two of three sampled residents during significant changes in their condition. For one resident with chronic obstructive pulmonary disease and severe cognitive impairment, the resident called 911 due to difficulty breathing and was transferred to a general acute care hospital without the physician being notified of the change in condition or the transfer. The licensed vocational nurse confirmed that the physician was not informed as required. For another resident with epilepsy, schizophrenia, and bipolar disorder, documentation showed new skin redness and later episodes of undressing, refusal of care, and increased confusion. In both instances, the facility's records indicated that the physician was either not clearly informed or there was no follow-up or escalation to the medical director when a response was not received. The facility's policy requires immediate notification of the physician and responsible parties in the event of significant changes in a resident's condition, but this was not followed in these cases.
Failure to Prevent Unauthorized Use of Physical Restraints
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from physical restraints, as required by facility policy and federal regulations. The resident, who had severe cognitive impairment and multiple diagnoses including bipolar disorder and chronic pain syndrome, was admitted with significant assistance needs for daily activities. On the night in question, the resident became agitated, was kicking during care, and was not redirectable. In response, a registered nurse and a certified nurse assistant restrained the resident by wrapping and tying a bed sheet around the resident's legs and securing it to the bed frame to restrict movement and prevent falls. Prior to applying the restraint, staff did not assess the resident for possible causes of the behavior, nor did they attempt less restrictive interventions. The physician was not notified of the resident's continued agitation, and no physician order was obtained for the use of physical restraints. Additionally, there was no care plan developed to address the need for restraints, and the resident's responsible party was not informed. The medication Lorazepam was administered but was reported as ineffective by the nurse, although the medication administration record indicated it was effective. The restraint was discovered by another CNA and a certified occupational therapist assistant during morning rounds, at which point the restraint was removed and reported to a licensed vocational nurse. Interviews with staff and facility leadership confirmed that the use of the restraint was not in accordance with facility policy, which requires assessment, physician order, and use of the least restrictive alternatives. Staff involved acknowledged that the restraint was applied without proper procedures and that it was poor judgment.
Failure to Obtain Informed Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain informed consent prior to administering Ativan to a resident with severe cognitive impairment and anxiety disorder. The resident was admitted with chronic obstructive pulmonary disease and anxiety, and had an order for Ativan 0.5 mg every six hours as needed for anxiety manifested by restlessness. The medication was administered before the informed consent form was signed by the resident or their representative, as confirmed by the Director of Nursing, who acknowledged that consent should be obtained before giving any psychotropic medication. Additionally, the facility did not properly monitor and document manifested behaviors for the administration of Ativan and Seroquel for another resident with severe cognitive impairment, bipolar disorder, and chronic pain syndrome. The medication administration record showed that Ativan and Seroquel were given, but the required tallying of behavioral episodes was not completed as ordered. Instead of recording the number of episodes, only check marks were used, which did not provide the necessary information for the physician to assess the appropriateness of the medication. The facility's policy requires that psychotropic medications be used only after non-drug interventions have been attempted, and that all medications used to treat behaviors must be monitored for efficacy, risks, and adverse consequences. The policy also states that informed consent must be obtained prior to administration and that staff should use behavioral monitoring charts to track triggers, episodes, and responses. These procedures were not followed in the cases reviewed, resulting in deficiencies related to the use and monitoring of psychotropic medications.
Failure to Initiate Fall Risk Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to initiate a fall risk care plan for a resident who was identified as being at risk for falls. Upon admission, the resident had diagnoses including hyponatremia and nontraumatic intracerebral hemorrhage, and was documented as having severe cognitive impairment, requiring maximal to total assistance with activities of daily living. Nursing documentation prior to the incident identified multiple fall risk factors, such as disorientation, poor safety judgment, unsteady gait, and use of psychotropic medications. Despite these findings, no fall interventions were ordered and no fall risk care plan was initiated prior to the resident experiencing a fall. The resident subsequently fell and sustained a skin tear to the right elbow. Interviews with facility staff confirmed that a baseline care plan addressing fall risk should have been developed within 48 hours of admission, in accordance with facility policy. However, the care plan for fall risk was not initiated until after the fall occurred. Facility policies reviewed indicated that residents identified as at risk for falls should receive appropriate interventions and an individualized plan of care, which was not implemented in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the General Acute Care Hospital (GACH) determining the resident was appropriate for transfer back. The resident, who had been admitted to the facility with diagnoses including alcohol cirrhosis of the liver with ascites and portal hypertension, was transferred to the GACH due to blood in her urine. The resident remained in the GACH for 20 days after the hospital attempted to transfer her back to the facility. The facility's Director of Nursing (DON) and Admissions Director (AD) did not readmit the resident due to concerns about an active Clostridium difficile (C. diff) infection, requiring contact isolation in a private room, which was not available. The facility's policy indicated that residents asymptomatic for 48 hours could be removed from precautions, but the DON and AD did not verify if the resident had symptoms of diarrhea at the time of the attempted readmission. The Administrator (ADM) was unaware that the resident could be taken off isolation after 48 hours without symptoms and share a room with another resident. The facility's failure to evaluate the resident's current condition and lack of communication regarding the resident's symptoms led to the deficiency, resulting in the resident's prolonged stay at the GACH.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in one resident being punched in the stomach by another resident. Resident 4, who was admitted with diagnoses including diabetes mellitus, dementia, bipolar disorder, and schizophrenia, was severely cognitively impaired and required assistance for all activities of daily living. On the day of the incident, Resident 4 reported being punched by Resident 5 while asleep, causing fear and confusion. Resident 5, who also had severe cognitive impairment and was dependent on staff for all activities of daily living, had a history of schizophrenia with agitation and poor impulse control. Despite this, the facility's care plan for Resident 5 aimed to prevent behavior problems. The incident was witnessed by an LVN who heard a commotion and confirmed the attack. The Director of Nursing acknowledged that Resident 5's behavior could have been more thoroughly analyzed, although no aggressive behaviors had been previously observed. The facility's policy emphasized abuse prevention, but the incident highlighted a failure in monitoring and intervention for residents with behavioral issues.
Failure to Maintain Resident Dignity During Verbal Altercation
Penalty
Summary
The facility failed to treat a resident with dignity when a Certified Nurse Assistant (CNA) spoke disrespectfully to the resident. The incident involved a resident with a history of bipolar disorder, major depressive disorder, generalized anxiety disorder, and other mental and behavioral disorders. The resident was cognitively intact and had a care plan addressing mood alteration behavior, which included interventions for staff to approach the resident calmly and redirect behavior positively. Despite these guidelines, a verbal altercation occurred between the resident and CNA 1, where the CNA responded inappropriately to derogatory remarks made by the resident. The altercation escalated when CNA 1 returned to the resident's room and began speaking loudly after being provoked by the resident's derogatory language. Other staff members, including another CNA and a Licensed Vocational Nurse (LVN), witnessed the exchange and acknowledged that CNA 1 should have handled the situation differently by maintaining professionalism and possibly seeking assistance from a supervisor. The Director of Nursing (DON) and the Administrator confirmed that CNA 1's response was not appropriate and did not align with the facility's policy on treating residents with dignity and respect.
Failure to Document Resident's Refusal of Psychiatric Care
Penalty
Summary
The facility failed to document a resident's refusal of a physician's visit, specifically psychiatric care and treatment, for a resident who was admitted with diagnoses of depression and anxiety disorder. The resident was cognitively intact and had the mental capacity to make medical decisions, as indicated in the Minimum Data Set and the physician's SOAP note. Despite this, there was no documentation of the resident's refusal of a psychiatric nurse practitioner's visit on a specific date, which was acknowledged by both the Licensed Vocational Nurse and the Director of Nursing during interviews. The Social Service Director was aware of the resident's refusal but did not document the nurse practitioner's visit in the resident's chart. The facility's policy requires timely documentation of physician visits to ensure continuity of care and respect for the resident's rights. The Director of Nursing confirmed that the resident's progress notes did not reflect the psychiatric nurse practitioner's visit or the resident's refusal, which should have been documented promptly to facilitate communication among staff and address the resident's needs.
Failure to Involve Resident Representatives in Care Planning
Penalty
Summary
The facility failed to ensure that the responsible parties (RPs) of a resident, who lacked the capacity to make decisions, were invited to and attended an Interdisciplinary Team (IDT) care conference. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, was involved in a fall incident. Despite the resident's cognitive impairment and the involvement of RPs in their care, the facility did not notify or include the RPs in the IDT meeting held to discuss the resident's fall and subsequent care plan. The IDT meeting was conducted following the resident's fall, which occurred when the resident attempted to reach for a water pitcher and slid out of bed, hitting their head. The meeting included various healthcare professionals but lacked the presence of the resident's RPs, who were listed as emergency contacts and involved in the resident's care. The absence of the RPs from the meeting was confirmed by the Social Services Director and the Director of Nursing, who acknowledged the oversight and its impact on the RPs' trust in the facility. The facility's policies and procedures emphasize the importance of involving resident representatives in care planning and decision-making. However, the failure to include the RPs in the IDT meeting violated these policies and the resident's rights. The RPs expressed frustration and concern over not being able to participate in discussions about the resident's care, particularly regarding the fall and measures to prevent future incidents.
Failure to Notify Responsible Parties of Missed COVID-19 Test
Penalty
Summary
The facility failed to notify a resident's primary care doctor and responsible parties when a COVID-19 test was not completed as ordered. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, was admitted to the facility and was supposed to be tested for COVID-19 via nasal swab as per physician orders. However, the test was not conducted, and there was no documentation indicating that the resident's doctor or responsible parties were informed of this failure. The Director of Nursing confirmed that the COVID-19 test was not completed as ordered and acknowledged that the facility did not inform the resident's doctor or responsible parties. This was identified as a violation of the resident's rights and an alteration in the resident's plan of care, resulting in a lack of ordered services. The facility's policies and procedures require that residents, legal representatives, and physicians be informed of any changes in the resident's condition, but this protocol was not followed in this case.
Failure to Safeguard Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure the personal belongings of a resident were properly accounted for and safeguarded. The resident, who was admitted with cerebral infarction, hypertension, heart failure, and depression, was able to make reasonable decisions but was dependent on assistance for activities of daily living. Despite receiving a new debit card, the resident's inventory list was not updated to reflect this, and the resident chose to keep the card in his wallet rather than using the facility's safekeeping option. Observations revealed that the resident's bedside drawer was left open, exposing personal items such as documents and a wallet. The resident expressed concerns about the security of his belongings due to the inability to find the key to his lockable drawer. Interviews with facility staff, including CNAs and LVNs, indicated that while the resident preferred to keep items visible, staff were responsible for offering assistance in securing personal items. It was noted that the resident had been given a key to the drawer months prior, but the key was now missing. The facility's policy required all personal property to be listed and updated on an inventory form, but this was not adhered to in the case of the resident's debit card. Staff interviews highlighted a lack of coordination between the nursing and social services departments in maintaining accurate and updated personal effects inventories. The Director of Nursing Services emphasized the importance of residents feeling secure in their environment, both physically and mentally, and the need for proper accounting of personal items.
Failure to Implement Comprehensive Care Plan for Resident on Plavix
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was on Plavix, a blood thinner medication. The resident, who had a history of atherosclerotic heart disease, hypertensive heart disease, and hyperlipidemia, was admitted with an intact cognition and was dependent on staff for certain activities. The care plan indicated a high risk of bleeding and bruising due to anticoagulant therapy, with interventions to administer Plavix and monitor for abnormal bruising or bleeding. However, the facility did not document or monitor the resident's bruises, which were reported after an alleged incident with a CNA. The resident reported to a licensed nurse that a CNA had grabbed his arm too hard, resulting in bruises. Observations confirmed the presence of dark purplish to maroon discoloration on the resident's left arm and hand, and scattered ecchymosis on the right forearm. Despite the care plan's requirement to monitor for bruising due to Plavix, there was no documentation of the bruises prior to the incident. Interviews with staff, including LVNs and the Treatment Nurse, revealed that the facility did not follow the care plan, and the bruises were not documented as a change of condition. The Director of Nursing confirmed the oversight and stated that it was the responsibility of licensed nurses to assess residents' skin. The facility's policy required the development and implementation of a comprehensive care plan with measurable objectives and time frames, but this was not adhered to in the case of the resident on Plavix. The lack of documentation and monitoring of the resident's bruises indicated a failure to follow the care plan and assess the resident's condition adequately.
Resident Injury Due to Overfilled Laundry Cart
Penalty
Summary
The facility failed to ensure that a housekeeper did not overfill a laundry cart, which obstructed her view and led to an accident involving a resident. The housekeeper was transporting a large blue laundry cart filled with clean linens and clothing, stacked higher than the rim of the cart, which blocked her visual field. As a result, the housekeeper accidentally ran over a resident's left foot with the cart, causing a fracture. The resident, who had been admitted with various diagnoses including type 2 diabetes and a previous fracture, was able to walk independently with supervision before the incident. After the accident, the resident experienced severe pain and swelling in the left foot, which was later diagnosed as a fracture of the left cuneiform bone. This injury resulted in the resident becoming wheelchair-dependent for mobility, significantly impacting her functional status. Interviews and observations revealed that the housekeeper did not report the incident immediately, and the laundry cart was observed to be piled high, obstructing the view. The facility's policy on laundry cart usage was not followed, as it specified that linens should not be stacked higher than the rim of the cart. The Director of Staff Development and other staff acknowledged that the accident could have been prevented if the housekeeper had a clear view while transporting the cart.
Failure to Maintain Range of Motion for Residents
Penalty
Summary
The facility failed to provide adequate services to maintain mobility and range of motion (ROM) for two residents, leading to significant deficiencies in their care. Resident 61, who had a history of cerebral infarction, hemiplegia, and other medical conditions, was not properly monitored or assessed for ROM in each joint of both arms and legs during quarterly Rehab Screenings from November 2021 to April 2024. The facility's policy required comprehensive assessments of ROM, but these were not conducted, resulting in a lack of detection and intervention for ROM limitations. Additionally, the facility did not provide passive range of motion (PROM) exercises to Resident 61's left arm as ordered by the physician from February 2022 to June 2022. Despite the resident's request for continued PROM exercises, documentation showed that these exercises were not performed consistently, leading to the development of contractures in the left elbow, forearm, and wrist. This failure caused pain and restricted the resident's ability to participate in activities of daily living, such as dressing and getting out of bed. Furthermore, the facility did not perform PROM exercises on specific dates as per the physician's orders, and there was a lack of monitoring and assessment for Resident 102's ROM during a quarterly Rehab Screening. These oversights resulted in Resident 61 experiencing pain and a decline in ROM, with the potential for further limitations in both legs and for Resident 102 to experience a decline in ROM without timely detection and intervention.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident 20, who was admitted with acute respiratory failure, vascular dementia, and dysphagia, was observed multiple times with the call light hanging out of reach. Despite having no cognitive impairment and requiring assistance for all activities of daily living, Resident 20 expressed difficulty in asking for help due to the inaccessible call light. The care plan for Resident 20 included an intervention to place the call light within reach, which was not followed. Similarly, Resident 57, who had diagnoses including congestive heart failure, dysphagia, and ischemic cardiomyopathy, was observed with the call light on the floor and out of reach. Resident 57 had moderate cognitive impairment and required dependent assistance for various activities. The care plan for Resident 57 also included an intervention to ensure the call light was within reach, which was not adhered to. Interviews with staff, including a CNA and the Director of Staff Development, highlighted the importance of having the call light accessible to prevent restlessness, frustration, and potential falls. The facility's policy on answering call lights emphasized the need for accessibility, which was not maintained in these cases.
Failure to Notify Nursing and Physician of Change in Condition
Penalty
Summary
The facility failed to notify nursing and the primary physician of a change in condition for two residents, leading to a deficiency in care. Resident 61, who was admitted with multiple diagnoses including cerebral infarction and hemiplegia, experienced increased pain and range of motion impairments in the left leg. Despite a Rehab Screening indicating the need for physical therapy services to prevent contractures and improve pain and range of motion, the resident did not receive a physical therapy evaluation or intervention. Observations revealed that Resident 61 was experiencing severe pain and had not been receiving the prescribed exercises, which were crucial for maintaining joint mobility. Similarly, Resident 102, admitted with conditions such as pain in the right elbow and psychosis, showed a significant decline in mobility and activities of daily living. A Rehab Screening noted impairments in both arms and one leg, and a significant decline in mobility, range of motion, and ADLs. However, this change in condition was not reported to nursing, and the resident did not receive any physical or occupational therapy services following the screening. The lack of intervention prevented the resident from receiving necessary care to address the decline in physical status. The facility's policy required immediate notification of the resident and consultation with the physician in cases of significant changes in physical status. However, in both cases, the changes were not communicated to the nursing staff or the physician, resulting in a failure to alter treatment plans accordingly. This oversight in communication and intervention led to the residents not receiving the necessary care to address their deteriorating conditions.
Failure to Update PASARR and Follow Recommendations
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) assessment was resubmitted for a resident who was newly diagnosed with a mental illness. Resident 89 was initially admitted with diagnoses including schizoaffective disorder and unspecified dementia. Despite having an active diagnosis of schizophrenia and being prescribed Seroquel for schizoaffective disorder, the PASARR was not updated to reflect the new diagnosis, which was an oversight by the Minimum Data Set Coordinator (MDSC). Additionally, the facility did not follow up on PASARR recommendations to obtain Level II evaluations for three other residents, Residents 11, 15, and 57. Resident 11 had severe cognitive impairment and was dependent on all activities of daily living, with diagnoses including schizophrenia and unspecified dementia. Resident 15 had severe cognitive impairment and required dependent assistance for all activities of daily living, with diagnoses including bipolar disorder and paranoid schizophrenia. Resident 57 had moderate cognitive impairment and required assistance with various activities, with diagnoses including congestive heart failure and ischemic cardiomyopathy. The Director of Nursing (DON) acknowledged that residents who are PASARR I positive need a PASARR II evaluation, especially when taking combinations of psychotropic medications. The facility's policy on psychotropic medication use requires informing residents and/or their representatives about the initiation, reason for use, and associated risks of such medications. However, the facility failed to adhere to these procedures, resulting in the potential for residents not receiving the necessary psychiatric evaluations and treatments.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the availability and administration of Restasis, a medication used to treat dry eye disease, for a resident. The resident was admitted with a diagnosis of dry eye syndrome and required Restasis as per physician orders. However, during a medication administration observation, it was noted that the medication was not in stock, and the resident did not receive it as prescribed. The Licensed Vocational Nurse (LVN) acknowledged the oversight and mentioned that the medication should have been ordered in advance. The Director of Nurses (DON) confirmed that the medication was essential for treating the resident's condition and that the physician should have been notified about the unavailability. The facility also failed to maintain accurate documentation of clonazepam, a controlled substance, for another resident. The resident was prescribed clonazepam for generalized anxiety disorder, but during a medication cart inspection, it was discovered that the controlled drug record was not updated to reflect the administration of the medication. The LVN admitted to documenting the administration in the electronic health record but not on the controlled drug record, which is crucial for preventing misuse and ensuring accountability. The DON emphasized the importance of accurate documentation to prevent discrepancies and potential abuse of controlled substances. Additionally, the facility did not apply lidocaine cream as per physician orders for a third resident. The resident was supposed to receive the cream on the right shoulder for pain relief, but it was instead applied to the left knee on multiple occasions. This misapplication was observed over several months, and the resident continued to experience pain in the left knee. The DON confirmed that the cream was not applied according to the physician's orders, which could have impacted the resident's pain management. The facility's policy requires medications to be administered as per the attending physician's written orders.
Failure to Date Prepared Food in Refrigerator
Penalty
Summary
The facility failed to adhere to its policy on food handling and storage, specifically regarding the dating of prepared food stored in the refrigerator. During an observation and interview with the Dietary Supervisor, it was noted that snacks and nourishment stored in the refrigerator were not labeled with either a preparation date or an expiration date. The Dietary Supervisor acknowledged that the snacks had just been prepared and were stored in the refrigerator to cool down for lunch service, but they were not labeled with the date of preparation. A review of the facility's policy and procedure on food receiving and storage indicated that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. This oversight in labeling had the potential to cause foodborne illnesses among residents who rely on the facility for their daily meals.
Infection Control Lapses in PPE Doffing and Medication Handling
Penalty
Summary
The facility failed to observe proper infection control measures for two residents, leading to potential infection risks. For Resident 48, the Assistant Minimum Data Set Coordinator (AMDSC) did not properly doff personal protective equipment (PPE) after addressing an issue with the resident's feeding pump. The AMDSC admitted to removing the gown before the gloves, contrary to the correct procedure, which could lead to contamination and infection spread. The facility's policy and an online article both emphasize the importance of removing gloves first to prevent self-contamination. In the case of Resident 80, a Licensed Vocational Nurse (LVN) placed a medication tray next to a urinal on the bedside table during medication administration. The urinal contained yellow liquid, creating an unsanitary condition for medication handling. The LVN acknowledged the resident's preference for the urinal's placement but did not adhere to the facility's policy, which requires urinals to be in a container to prevent infection risks. The Director of Nurses (DON) confirmed that the urinal should be hung with a dignity bag to avoid cross-contamination. Both incidents highlight lapses in adhering to infection prevention protocols, as outlined in the facility's Infection Prevention and Control Program. The program emphasizes the importance of educating staff and ensuring adherence to proper techniques to prevent the transmission of infections. These deficiencies in infection control practices could potentially lead to the spread of infections among residents, staff, and visitors.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for three residents by prescribing antibiotics without meeting the necessary criteria outlined in their protocol. The residents involved were prescribed topical antibiotics without documentation showing they met the required criteria for antibiotic treatment. Specifically, Resident 12 was prescribed Ketoconazole cream for eczema, Resident 47 for seborrheic dermatitis, and Resident 111 was prescribed clindamycin phosphate for furunculosis. The Infection Preventionist (IP) confirmed that the facility uses McGeer's criteria, which requires at least three criteria to be present before starting antibiotic treatment, but there was no documentation supporting that these criteria were met for the three residents. The facility's policy on antibiotic stewardship, dated September 18, 2023, states that antibiotics should be prescribed and administered under the guidance of the stewardship program, which includes reviewing culture and sensitivity results and the current clinical situation before starting, continuing, modifying, or discontinuing antibiotic therapy. However, the review and interviews revealed that the facility did not adhere to this policy, as there was no evidence that the necessary criteria were met for the residents to receive antibiotic treatment. This oversight had the potential to put the residents at risk for developing antibiotic resistance.
Failure to Track and Update COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain an updated record of COVID-19 vaccination status for both staff and residents, which was identified during an interview with the Infection Preventionist Nurse (IPN). The IPN, who assumed the role in April 2024, acknowledged that the last update to the vaccination status list was in March 2024. The IPN admitted to not having current information on who among the staff and residents were vaccinated or unvaccinated and also lacked educational resources for staff regarding COVID-19 vaccines. This lapse in documentation and education was further evidenced by the review of the facility's COVID-19 Staff Vaccine Log, which showed that seven staff members had no documented vaccination status, and 11 new hires since April 2024 were not listed on the log. Additionally, the Residents Vaccination Status Log lacked any information on the COVID-19 vaccination status of residents, failing to indicate whether they were vaccinated or unvaccinated. The Director of Nursing (DON) confirmed that COVID-19 immunization should be offered to both staff and residents to prevent the spread of the virus. The facility's policy and procedure documents outlined the requirement for offering vaccines, providing education, and maintaining documentation, but these were not adhered to, as evidenced by the lack of updated records and educational initiatives.
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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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