Ocean Pointe Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1330 17th Street, Santa Monica, California 90404
- CMS Provider Number
- 055155
- Inspections on file
- 45
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Ocean Pointe Healthcare Center during CMS and state inspections, most recent first.
A resident with CHF, DM, mobility difficulties, and depression, who was cognitively intact, reported being hit in the mouth and head on multiple occasions by another resident with COPD, CKD, dementia, and a documented history of physical and verbal aggression. Staff acknowledged a history of conflict between the two residents and that an incident had occurred days earlier, and progress notes showed prior aggressive behavior by the alleged aggressor. However, no nursing assessment (such as a skin check), change-of-condition evaluation, SBAR communication, or related documentation was completed or recorded after the abuse allegation, despite facility policies requiring assessment, monitoring, physician/responsible party notification, and charting when abuse or physical aggression is reported.
Two residents with significant care needs experienced delays in staff response to their call lights, despite staff being present at the nursing station. One resident, with a history of falls and muscle weakness, waited for assistance with morning medications, while another, totally dependent on staff, also had an active call light ignored for several minutes. Staff interviews confirmed that call lights were not always answered promptly, contrary to facility policy.
A treatment nurse and a CNA did not wear required PPE while performing a suprapubic catheter change for a resident on Enhanced Barrier Precautions. The resident had multiple medical conditions and required significant assistance. Facility policy and physician orders required staff to use PPE for such care, but this protocol was not followed during the observed procedure.
A resident with multiple diagnoses and moderate cognitive impairment had abnormal urinalysis results indicating possible infection, but the facility failed to notify the physician or responsible party and did not document the change in condition as required by policy.
A resident with a history of convulsions, sepsis, and CHF did not receive prescribed Depakote within the required time frames on two occasions, as confirmed by MAAR review and DON interview. The resident reported having a seizure due to delayed anti-seizure medication administration, and the DON acknowledged the deviation from policy requiring medications to be given within one hour of the scheduled time.
A resident with an indwelling urinary catheter who complained of pain and was found to have sediments in the catheter did not have these findings documented or reported to the physician by the treatment nurse. The nurse also did not check or record vital signs, contrary to facility policy, resulting in a deficiency in care to prevent UTIs.
A resident with severe cognitive impairment and multiple diagnoses had a change in dementia medication dosage, but the responsible party or POA was not notified as required by facility policy. Record review and staff interview confirmed the lack of documentation and notification regarding the medication change.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant change of condition, including low oxygen saturation and chest pain, leading to transfer to a hospital where a pulmonary embolism was diagnosed. Staff failed to document the change of condition, care provided, and physician orders for transfer, contrary to facility policy requiring such documentation for all significant events and changes in resident status.
The facility did not consistently complete, post, or retain required DHPPD forms, resulting in missing or incomplete daily nurse staffing information. This led to misinformation for all residents, families, and visitors about the actual staffing levels, as confirmed by the DSD during interviews and record reviews.
Surveyors found that opened food items in a refrigerator were not labeled with the required information, and the dry storage area lacked a thermometer to monitor temperature. The Dietary Supervisor and DON confirmed these lapses, which did not follow the facility's own food safety policies.
A leaking industrial washing machine was found in the laundry room, with a bucket and towels used to catch water and a puddle forming nearby. The Laundry Supervisor was unsure how long the leak had persisted, while the Maintenance Supervisor was aware but had not yet arranged for repairs. The Administrator was not informed of the issue, and the facility's maintenance policy requires equipment to be kept safe and operable. This failure had the potential to delay clean linen for all medically compromised residents.
Surveyors found that the laundry room floor had cracks and holes in front of the industrial washing machine, and the door leading to the dining hall was not functioning properly, with handles turning in different directions and failing to open or close as intended. Both the Laundry Supervisor and Maintenance Supervisor were unaware of the extent or duration of these issues prior to the survey.
A resident with dementia, muscle weakness, abnormal gait, and atrial fibrillation, who was assessed as high risk for falls, did not have bilateral floor mats in place as ordered by the physician and outlined in the care plan. During observation, the resident was found in bed with a bed pad alarm but without the required floor mats. Staff and the DON confirmed the omission, despite facility policy requiring such interventions for fall prevention.
A resident with a gastrostomy tube did not receive tube feeding as ordered when the feeding pump was left paused and alarming for at least 25 minutes, with the nurse unaware of the issue. Another resident receiving enteral hydration via g-tube had an unlabeled hydration bag, contrary to facility policy requiring labeling with the resident's name, date, time, and rate. These deficiencies involved residents with significant medical needs, including malnutrition and dysphagia, and were confirmed by nursing staff and policy review.
A facility failed to ensure a resident's safety after being notified of an APS case involving the resident's family member. Despite the resident's need for assistance and the family member's attempts to remove the resident without approval, no care plan was developed to address the risk. Staff interviews confirmed awareness of the APS case but revealed a lack of documented follow-up or monitoring plan.
A resident with multiple health conditions was discharged from the facility without necessary pre- and post-dialysis assessments, a discharge plan summary, or an IDT meeting, contrary to facility policy. Staff interviews confirmed the absence of these critical discharge steps, placing the resident at risk for harm.
A facility failed to develop a comprehensive care plan for a resident with an APS case involving a family member. Despite being informed of the case and the family member's attempts to remove the resident without approval, no care plan was created to address these issues. Staff interviews confirmed awareness of the situation but revealed a lack of documentation and planning to ensure the resident's safety.
A resident felt unsafe and uncomfortable due to their roommate's constant screaming and cursing, which was not reported by an LVN to the Facility Administrator. Both residents had severe cognitive impairments and required maximal assistance. The facility's policies emphasize supporting residents' dignity and well-being, but the failure to address the disruptive behavior potentially impacted the affected resident's psychosocial well-being.
A resident's family member reported grievances about the resident's roommate, who allegedly shouted racist slurs and threw coffee. The facility failed to resolve the grievance promptly and did not report or investigate the alleged abuse, as required by policy. The DSS called the police instead of addressing the issue internally, and the FA was not informed of the incidents.
The facility failed to report a suspected abuse incident involving a resident with severe cognitive impairment who was subjected to aggressive behavior by another resident. The Director of Social Services did not investigate or report the incident, and the Facility Administrator was not informed. This failure delayed an onsite inspection by the State Agency.
A facility failed to investigate allegations of abuse when a resident with severe cognitive impairment was reportedly subjected to aggressive behavior by another resident. The Director of Social Services did not investigate the claims, citing a lack of witnesses, and called the police due to the family member's agitation. The Facility Administrator was unaware of the incidents and did not report them, violating the facility's policy to investigate and report all allegations of abuse.
A facility experienced a nonfunctional call system affecting nine out of 62 residents, resulting in significant consequences. Residents experienced severe pain, distress, and delays in receiving assistance for activities of daily living and incontinence care. Some residents resorted to banging on tables, yelling, and using personal means like cell phones to contact staff. One resident's fall went initially unwitnessed, highlighting the lack of an alternate call system during the outage.
The facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards. Multiple food items in the kitchen were found without labels indicating a use-by date or an open date, and some items were expired. The Dietary Supervisor confirmed that all food items must have proper labeling to prevent food-borne illnesses.
A resident readmitted from a GACH with significant weight loss did not have their physician notified, as required by facility policy. The dietician and infection preventionist were aware of the weight loss but did not take action, leading to a failure in communication and documentation.
The facility failed to ensure a safe homelike environment for eight ambulatory residents due to uneven surfaces in the hallways and resident rooms. Despite multiple attempts to address the issue, the floor remained uneven with small to medium-sized bubbles, creating a potential tripping hazard.
A facility failed to develop a comprehensive care plan for a resident prescribed Diazepam for anxiety. The resident, who had multiple diagnoses and required moderate assistance with daily activities, did not have a care plan in place for the medication, violating the facility's policy.
The facility failed to follow the physician's order for oxygen supplementation for a resident with a complex medical history, administering 1 liter per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by an LVN during an observation and interview, highlighting a deficiency in the care provided.
A resident experienced severe pain due to the facility's failure to administer pain medication as prescribed and a malfunctioning call light system. The resident, with multiple diagnoses including hemiplegia, reported a pain level of 9 out of 10 and had to wait two hours for pain relief.
The facility failed to post daily nurse staffing information in a prominent place accessible to residents and visitors. Observations and interviews revealed that the facility only posted Census and Direct Care Service Hours Per Patient Day (DHPPD) and was unaware of the requirement to post detailed nurse staffing data, including the total number of RNs, LVNs, and CNAs along with their actual work hours.
The facility failed to follow up on the consultant pharmacist's recommendations for two residents, leading to a deficiency. One resident did not receive recommended blood tests for Depakote, and another had unclear administration parameters for Midodrine. The DON confirmed that the necessary actions were not taken.
The facility failed to implement a safe water management program to prevent waterborne diseases, including Legionnaire's disease. The Maintenance Supervisor (MS) and Infection Preventionist (IP) conducted water testing and treatment internally without external laboratory support, relying on informal methods such as YouTube videos for guidance. This practice did not align with the facility's policy, which required oversight by a water management team and specific measures to control Legionella.
The facility failed to offer the pneumonia vaccine to a resident with multiple diagnoses and severely impaired cognitive skills, as per their policy. The Infection Preventionist admitted to missing the opportunity to offer the vaccine, which was required by the facility's policy.
Failure to Assess and Document After Resident-on-Resident Physical Altercation Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policies and procedures for alleged or suspected abuse, change in condition, and charting and documentation after a resident reported being physically assaulted by another resident. One resident, with diagnoses including congestive heart failure, difficulty in walking, Type II diabetes mellitus, and depression, and with intact cognitive skills for daily decision-making, reported that another resident had hit him in the mouth and on the head on multiple occasions over several days and that he had called the police about the most recent incident. The resident required moderate assistance to supervision for ADLs. The alleged aggressor resident had diagnoses including COPD, chronic kidney disease, and dementia, with moderately impaired cognitive skills for daily decisions and a need for moderate to maximal assistance with ADLs. Progress notes for this resident documented ongoing monitoring for repeated physical and verbal aggression toward others and a prior incident of physical aggression in which the resident attempted to hit others with a walker in the hallway. Staff interviews confirmed there was a history of arguments and that the two residents did not get along, and that an incident had occurred a few days prior to the survey. Despite the report of physical aggression, the DON acknowledged that no nursing assessments, such as a skin assessment, were completed for the resident who reported being hit, and that she did not perform a nursing assessment herself. Review of the medical record by the Medical Records Director confirmed there was no nursing documentation related to the allegation, including no change of condition or SBAR documentation to reflect any assessment or monitoring after the report. The Administrator stated that complete documentation with nursing assessment, such as change of condition and/or SBAR, is required when a resident reports any type of abuse or physical aggression. These findings show the facility did not follow its own policies requiring assessment, monitoring, physician and responsible party notification, and documentation when a resident reports alleged abuse or physical altercation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that residents' call lights were answered promptly for two of three sampled residents. For one resident with a history of falls, muscle weakness, fibromyalgia, and difficulty walking, observations showed that the call light was activated and audible for seven minutes while three staff members were present at the nursing station but did not respond. The resident later reported that she had pressed the call light about 20 minutes prior because she needed her morning medications, and that staff sometimes did not answer the call light at all. Her care plan required that the call light and personal items be kept within reach due to her high risk for falls and injury. Another resident, who was totally dependent on staff for activities of daily living and had a history of metabolic encephalopathy and falls, also experienced delayed response to the call light. The call light was observed to be active for eight minutes while two staff members were present at the nursing station but did not respond. Interviews with staff revealed that some were occupied with other tasks or were from the registry and did not respond to the call lights. Facility policy required all staff to promptly respond to activated call lights, regardless of their assignment or employment status.
Failure to Use PPE During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention protocols when a treatment nurse and a certified nurse assistant did not wear the required personal protective equipment (PPE) during a suprapubic catheter change for a resident on Enhanced Barrier Precautions (EBP). Observation revealed that neither staff member donned complete PPE, despite signage indicating EBP outside the resident's room and a physician's order specifying the need for enhanced precautions due to the presence of a suprapubic catheter. The facility's policies and procedures require staff to perform hand hygiene and wear gowns and gloves for high-contact care activities, including catheter care, but these protocols were not followed during the observed procedure. The resident involved had multiple diagnoses, including hypertension, type 2 diabetes mellitus, Alzheimer's disease, and obstructive uropathy, and was assessed as having severe cognitive impairment and requiring moderate to maximum assistance with activities of daily living. Interviews with the treatment nurse and the infection preventionist confirmed that the facility's EBP protocol was not observed during the catheter change, and both acknowledged the expectation for staff to use proper PPE to prevent the spread of multidrug-resistant organisms. Review of facility policies further confirmed the requirement for PPE use during such procedures.
Failure to Notify Physician and Document Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in condition for a resident who exhibited abnormal laboratory results. The resident, who had diagnoses including metabolic encephalopathy, hypertension, and dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. A urinalysis revealed several abnormal findings, including turbid urine, moderate blood, positive protein, large leukoesterase, elevated white blood cells, and moderate bacteria, all of which were flagged as abnormal. Despite receiving these abnormal lab results, the Registered Nurse Supervisor confirmed that there was no documented evidence that the physician or the resident's responsible party was notified. Additionally, there was no documentation of an SBAR (Situation, Background, Assessment, Recommendation) or progress notes indicating that the physician had been informed, even though the nurse had received the results. The Director of Nursing also confirmed that abnormal urinalysis results are considered a significant change in condition and require prompt notification of the physician and responsible party, as well as proper documentation, none of which occurred in this case. A review of the facility's policies and procedures indicated that staff are required to promptly notify the attending physician and the resident's representative of any significant changes in the resident's condition, including abnormal lab results. The policies also require documentation of how, when, and to whom the information was provided. In this instance, the required notifications and documentation were not completed, resulting in a deficiency.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when the facility failed to administer medications to a resident in accordance with physician orders and the facility's policy and procedure for medication administration. The resident, who had diagnoses including unspecified convulsions, sepsis, and congestive heart failure, was prescribed Depakote in specific dosages and at scheduled times. Review of the Medication Administration Audit Record (MAAR) showed that on two occasions, the resident's Depakote was not administered within the required one-hour window of the scheduled time. Specifically, the 125 mg Depakote tablets scheduled for 5 p.m. were given at 9:42 p.m., and the 250 mg Depakote tablet scheduled for 9 a.m. was administered at 11:24 a.m. During interviews, the resident reported experiencing a seizure while in the facility, attributing it to not receiving anti-seizure medication on time. The Director of Nursing (DON) confirmed the medication administration times did not comply with the facility's policy, which requires medications to be given within one hour of the scheduled time unless otherwise specified. The facility's policy and the DON both acknowledged that failure to administer Depakote on time could result in convulsions.
Failure to Notify Physician and Document Catheter Complications
Penalty
Summary
A resident with a history of urinary tract infection (UTI), sepsis, and congestive heart failure was admitted with an indwelling urinary catheter and identified as high risk for developing complications, including UTI. The resident's care plan included interventions to assess for and record any changes in bladder status and to notify the physician of signs and symptoms of UTI. On review, it was found that the resident complained of pain, and a treatment nurse observed sediments in the resident's catheter after removal. However, the nurse did not notify the physician of the observed sediments, did not document the finding, and did not check or record the resident's vital signs, including temperature. The Director of Nursing confirmed that the resident's complaints and the observation of sediments should have been documented and reported to the physician, as per facility policy. The facility's policy required staff to observe for complications associated with urinary catheters, report any complaints of pain, and notify the physician or supervisor of any unusual findings. The failure to document and communicate these findings constituted a deficiency in providing appropriate care and services to prevent urinary tract infections.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to follow its policy and procedures regarding resident rights by not informing the responsible party (RP) or power of attorney (POA) about a change in a resident's medication dosage. The resident in question had severe cognitive impairment and multiple diagnoses, including dementia, muscle weakness, dysphagia, hyperlipidemia, and hypothyroidism. The resident was admitted with a designated RP/POA due to their inability to make decisions independently. A review of the resident's records showed that the dosage of Donepezil, a medication used to treat dementia symptoms, was decreased from 15 mg to 10 mg per day by the physician. Despite this significant change in medication, there was no documentation in the nursing or physician progress notes indicating that the RP/POA was notified of the change. The Director of Staff Development confirmed during an interview and record review that there was no evidence of notification and acknowledged that such changes should be reported to the responsible party, as it is their right to know. The facility's policy on resident rights, revised in January 2025, states that residents and their legal representatives must be informed of any changes in medical condition or treatment, which was not followed in this instance.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who experienced a significant change of condition (COC) that resulted in transfer to a general acute care hospital. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was observed by staff to be crying, complaining of chest pain, and had an oxygen saturation of 82%. Paramedics were called, and the resident was subsequently transferred to the hospital, where she was diagnosed with bilateral extensive pulmonary embolism and admitted for treatment. Despite these events, there was no documented evidence in the resident's medical record of the COC, progress notes, or physician orders for the transfer to the hospital. Interviews with nursing staff and a review of facility policies confirmed that documentation of such events is required, including completion of a COC form, progress notes, and notification of the physician and family. The lack of documentation meant that the resident's condition and the care provided were not accurately reflected in the medical record. Facility policies reviewed indicated that all changes in a resident's condition, services provided, and significant events must be documented to facilitate communication among the interdisciplinary team and ensure continuity of care. The failure to document the resident's COC and related interventions was not in accordance with accepted professional standards and the facility's own policies and procedures.
Failure to Accurately Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, specifically the Direct Hours Patient Day (DHPPD) forms, was accurately completed, posted in a prominent and accessible location, and retained for the required minimum of 18 months. During interviews and record reviews, it was found that DHPPD forms for several dates were missing, and some forms that were available lacked essential information such as beginning census, admissions, discharges, transfers, deaths, and actual direct care service hours. The Director of Staff Development (DSD) acknowledged responsibility for completing and posting these forms and confirmed the missing and incomplete records. The DSD also stated that the forms should be reviewed and signed by the DON or designee and be available for public review upon request. The facility's policy and procedure required posting the number of nursing personnel providing direct care for each shift and retaining these records for at least 18 months. However, the review revealed that these requirements were not consistently met, resulting in misinformation for all 63 residents, their families, and visitors regarding daily nurse staffing data. The deficiencies were identified through concurrent interviews and record reviews, with the DSD confirming the lapses in documentation and posting practices.
Failure to Label Opened Food and Monitor Dry Storage Temperature
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices. Specifically, in one of the reach-in refrigerators, three halved avocados were found wrapped in saran wrap without any labeling to indicate the name of the food item, the date it was opened, or its expiration date. The Dietary Supervisor confirmed that opened avocados should be labeled and dated, and acknowledged that this was not done. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date. Additionally, the kitchen's dry storage room was found to be lacking a room thermometer. The Dietary Supervisor confirmed the absence of a thermometer and stated that it is necessary to monitor the ambient temperature to prevent food spoilage. The facility's policy indicates that non-refrigerated foods should be stored in a temperature and humidity-controlled environment. The Director of Nursing also stated that staff are expected to follow safe food practices to prevent the spread of foodborne illness among residents.
Leaking Industrial Washing Machine Not Repaired
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the industrial washing machine used for laundering both facility linen and residents' clothing was not leaking. During an observation, a red bucket with towels was found placed under the washing machine to catch leaking water, resulting in a medium to large puddle in the immediate area. The Laundry Supervisor was unsure how long the machine had been leaking and deferred to the Maintenance Supervisor, who confirmed awareness of the leak and stated that a part was needed for repair. The Maintenance Supervisor indicated that the repair person would be informed about the issue. The Administrator was not aware of the leaking washing machine or the condition of the laundry room floor and stated that the damaged machine had not been reported. A review of the facility's maintenance policy revealed that the maintenance department is responsible for keeping all equipment in a safe and operable manner at all times, including maintaining the building in good repair and free from hazards. The failure to address the leaking washing machine had the potential to delay the provision of clean and sanitary linen for all 63 medically compromised residents who rely on staff for a homelike environment.
Unsafe Laundry Room Floor and Malfunctioning Dining Hall Door
Penalty
Summary
The facility failed to maintain a safe and operable environment in two key areas. In the laundry room, the floor in front of the industrial washing machine was observed to be cracked with medium to large holes in the concrete, creating an unsafe walkway. The Laundry Supervisor was unaware of the duration of the disrepair, as all repairs are managed by the Maintenance Supervisor. The Maintenance Supervisor acknowledged the floor had been in disrepair for some time and had discussed the need for repairs with the administrator, who was also unaware of the current condition of the floor. Additionally, the door leading from the hallway to the resident dining hall was found to be malfunctioning. The door did not remain shut when closed, would not open properly, and the handles on either side of the door turned in different directions. The Maintenance Supervisor was not aware of the malfunctioning door handle prior to the observation. Facility policy requires the maintenance department to keep the building and equipment in a safe and operable manner at all times, but these deficiencies were present at the time of the survey.
Failure to Provide Ordered Fall Prevention Equipment for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls and injury had bilateral floor mats in place as ordered by the physician and as specified in the resident's care plan. The resident, who had diagnoses including dementia, muscle weakness, abnormal gait and mobility, and atrial fibrillation, was admitted with a physician order for bilateral floor mats to be used for fall management. The resident's care plan and fall risk assessment both indicated the need for these mats due to the resident's high risk for falls and injury. During an observation, the resident was found lying in bed with a bed pad alarm, but no floor mats were present on either side of the bed. Staff interviews confirmed that the floor mats were not in place and that the resident should have had them according to the physician's order and care plan. The DON acknowledged that the resident had a history of overestimating their ability to walk and transfer, had experienced a previous fall, and was at increased risk for injury without the mats. The facility's policy on falls management required providing a hazard-free environment and adequate supervision, including the use of assistive devices such as floor mats, but this was not followed in the resident's case.
Failure to Administer and Label Enteral Nutrition and Hydration as Ordered
Penalty
Summary
A resident with a gastrostomy tube (GT) and diagnoses including dysphagia, protein-calorie malnutrition, and dementia was admitted and readmitted to the facility. The resident's physician ordered Nutren 2.0 to be administered via enteral pump at a specific rate and duration. During observation, the resident's feeding pump was found paused and alarming, displaying a message that it had been idle for 10 minutes. The pump had not been restarted for at least 25 minutes, and the nurse present was unaware of the alarm or the reason for the pause. The Director of Nursing confirmed that staff may pause tube feedings for care or medication administration but are expected to restart them promptly to ensure adequate nutrition. Another resident with a gastrostomy tube and multiple diagnoses, including moderate protein-calorie malnutrition, adult failure to thrive, MRSA infection, dysphagia, and chronic kidney disease, was observed receiving enteral hydration. The hydration bag in use was not labeled with the resident's name, date, time of initiation, or rate, as required by facility policy. The Registered Nurse Supervisor acknowledged that the lack of labeling could result in the hydration not being changed as needed, and the DON emphasized the importance of labeling to prevent gastrointestinal issues. Facility policies reviewed indicated that enteral nutrition and hydration should be administered as ordered and that containers must be labeled with specific information to ensure safe and appropriate care. The observed failures included not restarting a resident's tube feeding pump in a timely manner and not labeling another resident's enteral hydration, both of which did not comply with established protocols and orders.
Failure to Monitor Resident's Safety Amid APS Case
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident after being notified of an active Adult Protective Services (APS) case involving the resident's family member. The resident, who was diagnosed with end-stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder, required moderate to maximal assistance for daily activities. Despite the facility being informed of the APS case and the family member's attempts to remove the resident without staff approval, there was no documentation or care plan developed to address the potential risk posed by the family member. Interviews with facility staff, including the Director of Nursing and the Social Services Assistant, confirmed awareness of the APS case but revealed a lack of documented follow-up or care plan to monitor the family member's interactions with the resident. The facility's policy on abuse investigation and reporting mandates prompt reporting and thorough investigation of abuse allegations, but this was not adhered to in this case, leaving the resident at risk of abuse and neglect.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with End Stage Renal Disease, chronic obstructive pulmonary disease, and anxiety disorder. The resident, who required moderate to maximal assistance for activities of daily living and used mobility aids, was discharged to home without a pre-dialysis and post-dialysis assessment on the day of discharge. Additionally, there was no documentation of a discharge plan summary or an Interdisciplinary Team meeting for discharge planning, as required by the facility's policy and procedure. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary assessments and documentation. The Social Services Assistant acknowledged discussing discharge planning with the resident but failed to document it or conduct an IDT meeting. The lack of these critical steps in the discharge process placed the resident at risk for harm due to an unsafe discharge, as noted by the Director of Nursing.
Failure to Implement Comprehensive Care Plan for Resident with APS Case
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident after being notified of an Adult Protective Services (APS) case involving the resident's family member. The resident, who was admitted with diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder, required moderate to maximal assistance for activities of daily living. Despite the facility being informed by a general acute care hospital about the APS case and the family member's attempts to remove the resident from the facility without approval, no care plan was developed to address these concerns. Interviews with facility staff, including a registered nurse, social services assistant, and the director of nursing, confirmed awareness of the APS case but revealed a lack of documentation and care planning to ensure the resident's safety. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not followed, potentially impacting the resident's health and safety.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring a safe and comfortable environment in their room. One resident, who had severe cognitive impairment and required maximal assistance for activities of daily living, expressed feeling unsafe and uncomfortable due to their roommate's constant screaming and cursing. The roommate, who also had severe cognitive impairment and required maximal assistance, was admitted with diagnoses including sepsis, anxiety, depression, and bipolar disorder. The disruptive behavior was noted by a Licensed Vocational Nurse (LVN), who was aware of the issue but did not report it to the Director of Social Services or the Facility Administrator as required. The Facility Administrator confirmed that they were not informed of the resident's concerns and emphasized that staff should report such issues immediately. The facility's policies on accommodation of needs, quality of life, and resident rights were reviewed, indicating that the environment and staff behaviors should support residents' dignity and well-being, and that staff should treat all residents with kindness, respect, and dignity. The failure to address the disruptive behavior of the roommate potentially impacted the psychosocial well-being of the affected resident and delayed necessary care.
Failure to Address Grievance and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly resolve a grievance involving a resident's family member who expressed concerns about the resident's roommate. The family member reported that the roommate was shouting racist slurs and allegedly threw coffee at the resident. Despite these serious allegations, the Director of Social Services (DSS) called the police for intervention instead of addressing the grievance through the facility's established procedures. The DSS claimed there was no documentation or witness to support the family member's claims and deemed police intervention necessary due to the family member's agitation. Additionally, the facility did not report or investigate the alleged violations of neglect and abuse as required by their policy. The Facility Administrator (FA) was not informed of the incidents involving the roommate's disruptive behavior, which included screaming, cursing, and throwing objects at staff and residents. The FA acknowledged that the grievance report lacked a specific resolution and that further investigation should have been conducted. The facility's policy mandates prompt efforts to resolve grievances and requires reporting and investigation of any alleged violations, which were not adhered to in this case.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of abuse in accordance with state and federal law. This involved a resident who was subjected to aggressive behavior by another resident. The affected resident, who had severe cognitive impairment and required significant assistance for activities of daily living, was reportedly yelled at, screamed at, and had a cup of coffee thrown at them by another resident. The family member of the affected resident reported these concerns to the Director of Social Services (DSS), who did not take appropriate action to investigate or report the incident as required by the facility's policy. The DSS, upon being informed of the incident, called the police instead of conducting an internal investigation or reporting the incident to the appropriate authorities. The Facility Administrator was not informed of the incident and therefore did not report it either. The facility's policy, which mandates the prompt reporting of all allegations of abuse to the appropriate agencies, was not followed. This failure resulted in a delay of an onsite inspection by the State Agency to ensure the safety of the residents and had the potential to result in unidentified abuse within the facility.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policies and procedures by not conducting an investigation into a reasonable suspicion of abuse involving a resident. Resident 1, who was severely cognitively impaired and required significant assistance for activities of daily living, was reportedly subjected to aggressive behavior by Resident 2, who also had severe cognitive impairments and a history of behavioral issues. Resident 1's family member reported to the Director of Social Services (DSS) that Resident 2 was yelling, screaming, cursing, and had thrown a cup of coffee at Resident 1, raising concerns for Resident 1's safety. However, the DSS did not investigate these allegations, citing a lack of witnesses or documentation, and instead called the police due to the family member's agitation. The Facility Administrator (FA) was not informed of the incidents involving Resident 2, which included screaming, cursing, and throwing cups at staff and residents, and therefore did not report the incidents as required. The facility's policy mandates thorough investigation and reporting of all allegations of abuse, mistreatment, neglect, or injuries of unknown sources to the appropriate authorities, including the ombudsman, police, and state agency. The failure to investigate and report these incidents resulted in a delay of an onsite inspection by the State Agency, potentially leaving residents unprotected from possible abuse.
Nonfunctional Call System Leads to Resident Distress and Delayed Assistance
Penalty
Summary
The facility failed to provide an alternate call system for nine out of 62 residents when the main call system was nonfunctional from 3/9/2024 to 3/12/2024. This resulted in significant consequences for the residents. Resident 58 experienced severe pain in his left leg, rated at a level 9 out of 10, due to the nonfunctional call system and staff not responding to his calls for help. Other residents, including Residents 26, 49, 51, 64, 119, 120, 218, and 219, resorted to banging on tables, yelling, and screaming for assistance as the call system was not operational. Residents had to wait for extended periods for staff help, with some needing assistance for activities of daily living and incontinence care. The deficiency in the call system led to distress and discomfort among residents. Resident 26 expressed feeling petrified and uncomfortable, fearing an emergency situation due to the nonfunctional call system. Residents 49 and 64 had to use personal means, like a cell phone, to contact staff for assistance, highlighting the lack of alternative communication methods provided by the facility. Resident 218's fall went unwitnessed initially, with Resident 219 having to call for help and expressing a wish for the call system to be functional.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards and its policies for food service. During an observation and interview with the Dietary Supervisor, multiple food items in the kitchen were found without labels indicating a use-by date or an open date. Specific items included a container of dill weed, beans, green lentils, milk, prunes, peaches, apple sauce, tofu, strawberry sauce, tuna salad, hamburger dill chips, bananas, corn tortillas, lemons, and tomatoes. Some of these items were also found to be expired, such as the dill weed, strawberry sauce, and tuna salad. Additionally, a box containing bananas had a paper with a black substance, which could indicate contamination or spoilage. The Dietary Supervisor confirmed that all food items in the refrigerator and dry food storage area must have a label indicating when the food should be used by, and when food items are opened, there should also be an open date. The facility's policy and procedures titled 'Food Service Management' dated 2017, indicated that practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including leftovers, so it is used by its use-by date, or frozen where applicable or discarded. The failure to adhere to these policies had the potential to result in food-borne illness in medically vulnerable residents who consumed the food prepared by the facility kitchen.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to initiate a change of condition (COC) for a resident who was readmitted from a general acute care hospital (GACH) with significant weight loss. Specifically, the facility did not notify the resident's physician of the weight loss, which placed the resident at risk for further weight loss. The resident, who had multiple diagnoses including end-stage renal disease, chronic respiratory failure, and type 2 diabetes, was readmitted to the facility with a weight of 110 pounds, down from 135 pounds prior to hospitalization. The dietician noted the significant weight loss but stated that it was the nursing department's responsibility to notify the physician and the resident's family, which was not done. During interviews, the dietician and the infection preventionist (IP) both acknowledged awareness of the resident's significant weight loss but indicated that no action was taken to notify the physician because the weight loss occurred in the GACH. The facility's policies and procedures require that any changes in a resident's condition, including significant weight loss, be documented and communicated to the attending physician and responsible party. However, there was no documentation that the physician was notified, leading to a failure in communication and documentation as per the facility's policies.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe homelike environment for eight ambulatory residents due to uneven surfaces in the hallways and resident rooms. During an observation, it was noted that the hallway floor in front of several resident rooms and the Nurses' Station had bulged areas, creating a potential tripping hazard. The Maintenance Supervisor confirmed that the Administrator was aware of the issue and had attempted to address it by cutting the tiles to release air bubbles, but this method was unsuccessful. The floor remained uneven with small to medium-sized bubbles. The Administrator stated that the floor tiles were installed about four years ago, and issues with waves and bubbles appeared later. Despite multiple attempts by the company to reheat and flatten the tiles, the problem persisted. The facility's policies and procedures indicated that floors should be maintained in a clean, safe, and sanitary manner, and that maintenance services should ensure the building is free from hazards. However, the facility did not meet these standards, resulting in a potentially unsafe environment for the residents.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was placed on a psychotropic medication. The resident, who had multiple diagnoses including type 2 diabetes, anxiety disorder, and hypertension, was prescribed Diazepam for anxiety. However, during a review of the resident's care plans, it was found that there was no care plan in place for the use of Diazepam. This was confirmed by the Minimum Data Set Nurse, who acknowledged the absence of a care plan for the medication. The resident's Minimum Data Set indicated that they were cognitively intact and required moderate assistance with daily activities. Despite this, the facility did not have a care plan that included measurable objectives and timetables to meet the resident's needs related to the use of Diazepam. This oversight was in violation of the facility's own policy, which mandates a comprehensive, person-centered care plan for each resident.
Failure to Follow Physician's Order for Oxygen Supplementation
Penalty
Summary
The facility failed to follow the physician's order for oxygen supplementation for Resident 118. The resident, who has a complex medical history including chronic obstructive pulmonary disease, chronic respiratory failure, and other significant conditions, was observed receiving oxygen at 1 liter per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by Licensed Vocational Nurse 5 during an observation and interview, who acknowledged that the resident was not receiving the correct oxygen treatment as prescribed. The failure to administer the correct oxygen dosage could lead to increased shortness of breath for the resident. A review of the facility's policies and procedures indicated that there are guidelines for safe oxygen administration, which include verifying and following the physician's orders. Additionally, the facility's policy on physician orders mandates that medications and treatments be administered as ordered and monitored for accuracy. Despite these policies, the facility did not adhere to the physician's order for Resident 118, resulting in a deficiency in the care provided to the resident.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to administer pain medication in accordance with physician's orders and care plans for one resident, resulting in severe pain. Resident 58, who was admitted with diagnoses including toxic encephalopathy, muscle weakness, essential hypertension, and hemiplegia affecting the left side, experienced a pain level of 9 out of 10 in the left leg for two hours. The resident's pain management plan included Tylenol, Gabapentin, and Oxycodone, but the Medication Administration Record (MAR) did not indicate that any pain medication was administered or refused on a specific date. The resident reported that the call light system was not working for three days, making it difficult to receive pain medication on time, and had to wait in severe pain for two hours over a weekend. During an interview, the Director of Nursing confirmed that Resident 58 had a pain management care plan in place. The facility's policy on pain assessment and management emphasized a commitment to appropriate assessment and treatment of pain based on professional standards, the comprehensive care plan, and the resident's choices. However, the facility did not adhere to these guidelines, leading to the resident's prolonged and severe pain. The failure to administer prescribed pain medication and the malfunctioning call light system contributed to the deficiency.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. During observations on multiple dates, the nurse staffing data was not visible anywhere in the facility. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the requirement to post daily nurse staffing data, including the total number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs) along with their actual work hours. The facility only posted Census and Direct Care Service Hours Per Patient Day (DHPPD) daily, which did not meet the regulatory requirements. The facility's policy and procedures, dated August 2022, indicated that nurse staffing data should be posted daily for each shift and maintained for a minimum of 18 months. However, the facility did not comply with this policy. The DON and ADM admitted that the facility had never maintained specific hours for RNs, LVNs, and CNAs. This lack of compliance was confirmed through observations, interviews, and records review, leading to the deficiency noted in the report.
Failure to Follow Up on Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up and communicate with a physician regarding the consultant pharmacist's recommendation to perform blood tests for two residents, leading to a deficiency. Resident 49, who had multiple diagnoses including type 2 diabetes, hypertension, and a mood disorder, was prescribed Depakote. The Pharmacy Consultation Report recommended ordering several blood tests due to potential side effects of Depakote, but these tests were not ordered, and the recommendation was not signed or dated by a physician. The Director of Nursing (DON) confirmed that the lab tests were not done and could not provide documentation indicating otherwise. Similarly, Resident 51, who had a range of diagnoses including toxic encephalopathy, Parkinson's disease, and chronic obstructive pulmonary disease, was prescribed Midodrine for hypotension. The Drug Regimen Review recommended clarifying the administration parameters and frequency of Midodrine with a physician. However, the physician's orders did not include these parameters, and the Drug Regimen Review was neither signed nor dated, indicating it was not completed. The DON confirmed that the review was not done. The facility's policy on Medication Regimen Reviews requires the consultant pharmacist to review each resident's medication regimen monthly and provide a signed and dated report to the DON and medical director. The policy also mandates that physician responses be documented and maintained as part of the permanent medical record. The failure to follow these procedures resulted in the identified deficiency, as the necessary follow-up actions were not taken for Residents 49 and 51.
Failure to Implement Safe Water Management Program
Penalty
Summary
The facility failed to implement a safe water management program to prevent waterborne diseases, including Legionnaire's disease. During an interview, the Maintenance Supervisor (MS) revealed a lack of awareness about any water management program, although MS tested water temperatures and kept a log. The Infection Preventionist (IP) mentioned that maintenance increased water temperature to kill bacteria and that water tests were conducted twice a month using a mini-lab water testing kit. However, the MS admitted to using YouTube videos for guidance on water treatment and disinfection, and the facility did not employ an outside laboratory for water testing. Instead, water testing was conducted internally by the MS, IP, and Administrator (ADM). The ADM confirmed that water testing began at the start of 2024, with IP collecting samples from various facility areas and using a mini-lab test kit for testing. A review of the facility's policy and procedure (P&P) titled
Failure to Offer Pneumonia Vaccine to Resident
Penalty
Summary
The facility failed to ensure that pneumonia vaccines were offered and/or re-offered to a resident, as per their policy. Resident 29, who had multiple diagnoses including elevated white blood cell count, retention of urine, difficulty walking, muscle weakness, bipolar disorder, neuroleptic induced parkinsonism, mild cognitive impairment, tremors, hyperlipidemia, hypertension, allergic rhinitis, edema, and polyneuropathy, was not offered the pneumonia vaccine. The resident's Minimum Data Set indicated severely impaired cognitive skills and required maximal staff assistance for activities of daily living. During an interview and concurrent record review, the Infection Preventionist admitted to not locating any records indicating that Resident 29 had received the pneumonia vaccine. The facility's policy, dated February 2022, mandates that residents be informed about the benefits and risks of immunizations and be given the opportunity to receive the influenza and pneumococcal vaccines unless medically contraindicated, refused, or already immunized. The failure to offer the vaccine to Resident 29 was acknowledged by the Infection Preventionist as an oversight.
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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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