Orchards At Tulare
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulare, California.
- Location
- 604 E. Merritt Ave., Tulare, California 93274
- CMS Provider Number
- 056261
- Inspections on file
- 69
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Orchards At Tulare during CMS and state inspections, most recent first.
A resident’s written request for a copy of clinical records was received by MRP but not fulfilled until about two weeks later, despite facility policy requiring that residents or their legal representatives receive copies of their records within 2 working days of a request. During interview and record review, facility leadership confirmed that the “Release of Medical Records” policy was not followed, resulting in a delay and violation of the resident’s right to timely access to their medical information.
Surveyors found that ceiling vents in ten sampled resident rooms were covered with thick black dust-like debris, and one vent had black mold-like debris, indicating a failure to maintain a clean and homelike environment. A resident reported not seeing housekeeping clean their room, while housekeeping staff and the Housekeeping Supervisor acknowledged that vents were dirty, had not been cleaned in days, and that debris could fall on residents and get into their lungs. The Maintenance Lead stated he did not clean vents unless directed, and the IP, who holds monthly oversight meetings with housekeeping, reported not noticing dust issues. Review of the deep cleaning schedule, room rounds tools, and the routine cleaning/disinfection policy showed no specific instructions for cleaning ceiling vents, contributing to the lack of vent cleaning and buildup of debris.
A resident with severe cognitive impairment (BIMS score of 0) eloped from the facility when a newly hired CNA opened a secured front entrance door to allow visitors to leave and did not recognize the resident, who was standing among the visitors, as a non-visitor. The resident, who had no order to leave and was not considered safe to be outside unsupervised, exited without staff awareness and was later found in a parking lot across the street. Facility policies defined elopement as leaving without authorization or necessary supervision and required adequate supervision to prevent such accidents.
Surveyors found unsanitary conditions in the kitchen, including a dead cockroach and debris between refrigeration units, improper sanitization of the ice machine due to failure to follow manufacturer guidelines, and baseboards peeling away from the wall under a sink, creating a potential pest entry point. Staff were aware of these issues, which had been noted in audits, but no corrective actions or repairs had been implemented.
A resident with multiple medical conditions and significant weight loss did not receive comprehensive nutritional reassessment or effective monitoring of food, fluid, and supplement intake. The RD did not recalculate calorie, protein, or fluid needs after changes in condition, and staff failed to document or track the consumption of oral nutrition supplements. The facility also did not offer alternative supplements when the resident refused the standard option, and did not systematically monitor or address inadequate fluid intake, resulting in further decline and hospitalization.
A resident was not provided with the opportunity to formulate or decline an advance directive upon admission, as required by facility policy. Review of the medical record and interview with the Business Office Manager confirmed there was no documentation that this process occurred.
Two residents experienced delays in the replacement of personal belongings after reporting them lost, including a watch and a sweatshirt. Despite facility policy requiring replacement within seven days, the items were not replaced in a timely manner, and staff interviews confirmed the process was not followed.
A resident experienced a major decline in health, including significant unplanned weight loss and the development of new pressure ulcers, but the facility did not complete a Significant Change in Status Assessment (SCSA) as required. The MDS Coordinator acknowledged the oversight, and records showed the resident had ongoing nutritional and wound care needs that were not comprehensively reassessed following these changes.
The facility failed to maintain accurate and up-to-date MDS Matrix documentation for three residents, resulting in incorrect records of medication use and weight loss status. Errors included listing discontinued medications and misclassifying a resident's significant weight loss as being on a prescribed regimen, despite ongoing nutritional interventions. The MDS Coordinator acknowledged the lack of timely updates, leading to inaccurate assessments.
A resident with severe cognitive impairment and swallowing difficulties experienced a choking episode that was not promptly identified or addressed by nursing staff present in the dining room. After the incident, only a limited assessment was performed, and monitoring was inappropriately delegated to a non-nursing staff member. The family member feeding the resident was not educated on safe feeding practices, and the resident did not consistently receive prescribed thickened liquids, resulting in unidentified needs and improper care during the choking event.
A resident with chronic pain did not consistently receive her prescribed pain medication, as staff substituted Acetaminophen for Oxycodone without documented rationale, resulting in unmanaged pain and failure to follow the facility's pain management policy.
The facility did not ensure that controlled substances were destroyed in the presence of a pharmacist or that destruction was properly documented with both a nurse and pharmacist signature. Several entries in the medication destruction log for medications such as oxycodone, lorazepam, morphine, and hydrocodone were not properly dated or signed, and the pharmacy consultant confirmed no pharmacist was present during destruction. This resulted in incomplete documentation and lack of accountability for controlled medication disposal.
Three medication administration errors were observed, including failure by a respiratory therapist to instruct a resident to exhale and hold their breath when using inhalers, and an LPN administering insulin in the same site without rotation. These actions led to an 11% medication error rate during the observed period.
The facility did not follow the planned menu for a finger foods diet for a resident, serving a whole piece of cake instead of bite-sized pieces as required, and also failed to provide the full amount of fluid prescribed for another resident on a fluid restriction due to end stage renal disease. These deficiencies were identified through observation and record review, with staff confirming that established dietary protocols were not followed.
A resident with significant weight loss, decreased oral intake, and multiple wounds was not asked about beverage preferences and was only provided standard drinks available in the kitchen, despite expressing preferences for specific beverages like pineapple juice. The care plan and facility documentation did not include individualized beverage preferences, and staff confirmed that only routine drinks were offered, contrary to facility policy requiring person-centered hydration approaches.
A resident's medical record did not accurately document the administration and consumption of a prescribed oral nutrition supplement (HN shake) with breakfast. The supplement intake was combined with total fluid intake, and late entry documentation further compromised accuracy, making it difficult for the IDT to assess the effectiveness of the nutrition intervention.
A nurse administered injectable insulin to a resident and used her ungloved hand to uncap and dispose of the contaminated needle, contrary to facility policy requiring glove use and proper safety procedures. The nurse acknowledged the lapse during the observation.
A resident did not receive prescribed Seroquel XR on multiple occasions because the medication was not available, as documented in the MAR and progress notes. Nursing staff did not notify the pharmacy or physician about the missed doses, contrary to facility policy, and the DON confirmed the medication was not administered as ordered.
The facility did not follow its policy requiring staff to wear identification badges while on duty. Two CNAs were observed without their badges; one forgot it, and the other left it in her car. The DSD confirmed the policy, and a review of the facility's procedures indicated that all employees must wear identification badges during work hours.
A resident was not administered a prescribed medication for hyperlipidemia on multiple occasions because the medication was not available, pending delivery, or on order. Nursing staff did not contact the pharmacy or notify the physician as required by facility policy, resulting in missed doses.
A facility failed to maintain confidentiality of a resident's medical records when a staff member took and shared a screen shot of the resident's information via text message. The screen shot included sensitive details such as the resident's picture, birthdate, age, allergies, code status, and gender. Facility administrators confirmed the breach and acknowledged it violated HIPAA and facility policies.
A facility failed to refer a resident to a dermatologist as ordered by a physician, potentially delaying treatment. The resident had a dermatology consult ordered for a generalized rash, but 16 days later, the referral process had not been initiated. The LVN/IP could not provide documentation of the referral, and the SSD stated that referrals should be followed up within a week. The facility's policy required Social Services to collaborate with nursing staff to arrange for ordered services.
The facility failed to report a scabies outbreak to the California Department of Public Health (CDPH) after two residents were diagnosed. The outbreak was only reported to the county health department due to the lack of confirmed skin scraping, despite guidance indicating that an outbreak should be assumed following a single case. Interviews with staff revealed a misunderstanding of reporting requirements, resulting in CDPH being unaware of the outbreak.
A facility failed to implement physician orders for a resident, potentially worsening the resident's injuries. The orders included cleansing sutures and monitoring discoloration for signs of worsening. The treatments were not documented on specific shifts, and the DON confirmed the lack of documentation meant there was no way to verify if treatments were administered. This represents a deficiency in adhering to professional standards of care.
A resident with dementia was inaccurately assessed as low fall risk after a fall, despite severe cognitive impairment and a history of falls. The DON later confirmed the assessment was incorrect, as the resident was not oriented x3 and had a shuffling gait. The facility's policy required accurate risk assessments upon admission and significant changes.
A facility failed to protect residents from abuse, resulting in physical harm to one resident by a CNA and verbal abuse of another by an LVN. The first resident, with Alzheimer's and dementia, was unable to report the abuse, but a witness confirmed the CNA's actions, leading to multiple injuries. The second resident, cognitively intact, reported being called derogatory names by the LVN, corroborated by another resident and staff. These incidents violated the facility's abuse prevention policy.
A resident with multiple areas of discoloration was not immediately assessed or reported to the attending physician by an LVN, despite the facility's policy requiring such actions for significant changes in condition. The discolorations were initially reported by a CNA, but the LVN did not follow through, leading to a delay in treatment.
A resident with severe cognitive impairment and pressure ulcers was discharged without proper communication of care instructions to the responsible party (RP). The LVN discussed the discharge plan only with the resident, who had a BIMS score of 4, indicating severe cognitive impairment. The RP was not informed about the necessary wound care, leading to the resident's readmission to the hospital due to an infected wound.
The facility failed to follow the therapeutic menu for three residents, leading to potential unmet nutritional needs. A resident on a regular texture diet received a mechanical soft texture meal due to a shortage, and another resident did not receive the salad included in the menu. The Dietary Supervisor confirmed the discrepancies, acknowledging that the regular texture meal should have been served as planned.
A facility failed to notify a physician of a resident's elevated blood sugar levels, as required by the resident's care plan. The resident's blood sugar levels frequently exceeded 300 mg/dl, but there was no evidence of physician notification. This oversight was confirmed by the ADON, who acknowledged the failure to adhere to the facility's diabetes management protocol.
The facility failed to ensure proper medication storage, with unidentified pills found loose in medication carts. During observations, LVNs and the ADON confirmed that medications should not be loose in drawers. The facility's policy indicated medications should be stored in their original packaging.
A facility failed to implement a care plan for a resident after hospital readmission, as hospital records were not requested timely. This led to unawareness of the resident's non-weight-bearing status and follow-up needs after a fall causing a femur fracture. The resident was seen using a walker despite discharge instructions for non-weight bearing, and the necessary orders were delayed by 11 days.
A resident developed a rash that was documented on two separate occasions, but the physician was not notified until eight days later. The facility's policy requires notifying the physician of significant changes in a resident's condition, which was not followed in this case.
A resident involved in an incident with another resident sustained a skin tear and was recommended for laboratory tests following a psychiatric evaluation. However, the facility failed to complete the recommended tests, as confirmed by the DON, who found no documentation of the tests in the resident's clinical record. This was contrary to the facility's policy requiring staff to process and arrange for tests based on physician orders.
The facility failed to follow CDC infection control guidelines, conduct proper infection surveillance, and implement water management policies, affecting all 92 residents. Issues included improper hand hygiene, inadequate disinfection of medication carts, poor laundry conditions, and lack of water testing for Legionella.
The facility failed to ensure proper informed consent for psychotropic medications for four residents. Informed consent forms were incomplete or improperly filled out, with missing signatures from responsible parties and physicians. LVNs were explaining the risks, benefits, and alternatives instead of physicians, contrary to facility policy.
The facility failed to ensure that four residents had functional and accessible call lights. Observations revealed that call lights were either on the floor, not attached to the wall, not within reach, or not working. Staff confirmed that call lights should be within reach at all times, and the facility's policy indicated that the call system should remain functional at all times.
The facility failed to ensure that 10 out of 13 sampled residents or their representatives were provided with information and allowed to formulate advance directives. Additionally, the facility did not ensure that the Physician's Order for Life Sustaining Treatment (POLST) was properly ordered by the physician before being signed by the residents' representatives for two residents.
The facility failed to provide a summary of the Baseline Care Plan (BCP) within 48 hours of admission for two residents. One resident with Cerebral Palsy and another with metabolic encephalopathy did not receive their BCP summaries, and the BCPs were incomplete and unsigned. An LVN confirmed the BCPs were not given to the residents or their representatives.
The facility failed to provide documentation of competency and skill performance for six of eight sampled employees, including CNAs, an RNA, an RN, the ADON, and the IP. The Director of Staff Development acknowledged the absence of competency assessments, and the facility's required forms and policies were not followed, indicating a failure to ensure staff competency.
The facility failed to label opened food items with expiration dates and did not replace the ice machine's expired water filter as per guidelines. Opened food items and spices were found without proper labeling, and the ice machine's water filter was overdue for replacement. These issues were confirmed by the Interim Dietary Supervisor, Registered Dietitian, and Director of Maintenance.
The facility failed to provide proper oversight of their Infection Prevention and Control Program, resulting in the inappropriate removal and storage of residents' personal belongings during a scabies outbreak. Additionally, the facility lacked a water management program and did not implement a facility-specific Quality Assurance and Performance Improvement (QAPI) framework, putting residents and staff at risk.
The facility failed to provide the Binding Arbitration Agreement in simple, understandable language or in a language other than English. The Business Office Manager admitted that the facility did not have a language-assistance service and could not explain every paragraph of the agreement form. Additionally, the facility lacked policies and procedures for entering into a Binding Arbitration Agreement.
The facility failed to ensure a clean and homelike environment for a resident. During an observation, multiple splatters of a brown substance were found on the wall and floorboards next to the resident's bed. The DON acknowledged that the room was not clean or acceptable and noted that it appeared to have not been cleaned in a while, contrary to the facility's policy on cleanliness and order.
The facility failed to maintain good grooming and personal hygiene for a resident, resulting in long and dirty fingernails, and did not provide adequate oral care for another resident, leading to dental issues and plaque buildup. Staff confirmed the deficiencies, and facility policies were not followed adequately.
The facility failed to provide activities that met the interests of two residents, leading to expressions of boredom and dissatisfaction. One resident lacked reading materials, while another missed playing the guitar, which was not provided by the facility.
The facility failed to follow up on the status of hearing aids for two residents, leading to potential communication issues and loss of hearing abilities. Both residents had audiograms indicating significant hearing loss and were eligible for hearing aids, but the Social Services Director did not follow up as required by the facility's policy.
A resident admitted with a wound on the left hand did not receive weekly wound assessments for four weeks. Only one assessment was documented, and the facility could not provide a policy for weekly wound assessments. The DON confirmed that such assessments should be done.
A facility failed to administer prescribed treatment for a resident's hand contractures. Despite physician orders to cleanse the hand and place a rolled-up washcloth daily, observations and staff interviews revealed that this treatment was not being performed. Documentation also showed no records of the treatment over a specified period, and staff cited missing orders in their system as a reason for the oversight.
The facility failed to ensure proper communication and coordination with the dialysis center, as post-dialysis monitoring documentation was incomplete for two residents. This lapse was confirmed by an LVN and is contrary to the facility's hemodialysis policy.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for release of medical records when a written request for a resident’s clinical record was not fulfilled within the required timeframe. On 2/17/26, Medical Records Personnel (MRP) received a written request for Resident 1’s clinical record, but the record was not released until 3/9/26, resulting in approximately a 14‑day delay from the request date. During a concurrent interview and record review with the Administrator and MRP, MRP confirmed the dates of the request and release, and the Administrator confirmed that the facility’s policy titled “Release of Medical Records” was not followed. Review of the facility’s 2025 policy “Release of Medical Records” showed that residents or their legal representatives are to receive a copy of the medical record within 2 working days after the request is made. The failure to provide Resident 1’s clinical records within this 2‑working‑day timeframe constituted a violation of the resident’s right to access their records as specified in the facility’s own policy.
Failure to Maintain Clean and Sanitary Ceiling Vents in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain clean and sanitary ceiling vents in all ten sampled resident rooms, compromising residents’ right to a safe, clean, comfortable, and homelike environment. On multiple observations conducted on the same day, surveyors noted that ceiling vents in each of the identified rooms had thick black dust-like debris, and in one room a vent had black mold-like debris. A resident reported not having seen housekeeping cleaning their room. Housekeeping staff, including the housekeeper and the Housekeeping Supervisor, acknowledged during concurrent observations and interviews that the vents were dirty, needed to be cleaned, and that dirt from the vents could fall on residents and get into their lungs. The Housekeeping Supervisor stated that both Maintenance and housekeeping were responsible for cleaning the vents and admitted the vents had not been cleaned in days and that they had missed cleaning them, allowing buildup. The Maintenance Lead stated he did not do much cleaning and did not clean ceiling vents unless specifically instructed, indicating a lack of routine maintenance cleaning of vents. The Infection Preventionist reported not having noticed issues with dust, despite having monthly meetings with housekeeping for oversight, and stated that dusty or moldy vents would be a respiratory concern. Review of the facility’s Deep Clean Schedule and Room Rounds documentation showed no instructions for cleaning ceiling vents. The facility’s Routine Cleaning and Disinfection policy referenced cleaning from top to bottom and focusing on visibly soiled surfaces but did not specifically address ceiling vents, contributing to the omission of vent cleaning and the resulting accumulation of dust and debris in resident rooms.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision at Secured Exit
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for one resident with severely impaired cognition. A registered nurse reported that on 2/7/26 at approximately 10:38 a.m., she was informed that a male resident was outside the facility without supervision and was subsequently found in a parking lot across the street. The RN stated the resident was alert but had impaired cognition, did not have an order to leave the facility, and was not safe to be outside without supervision. Review of the resident’s quarterly MDS dated 1/16/26 showed a BIMS score of 0, indicating severe cognitive impairment. A CNA reported that at approximately 10:30 a.m. on the same day, he opened the secured front entrance door to allow visitors to exit and did not recognize that the cognitively impaired resident was standing among the visitors. The CNA stated the resident exited the facility without supervision when the door was opened. The facility’s 5-Day Follow-Up Report documented that the resident exited through the front entrance after a newly hired CNA opened the secured door for visitors and did not recognize the resident as a non-visitor. Review of facility policies titled “Elopements and Wandering Residents” and “Accidents and Supervision” indicated that elopement is defined as leaving the premises or a safe area without authorization and/or necessary supervision, and that the facility will provide adequate supervision to prevent accidents.
Unsanitary Kitchen Conditions and Improper Ice Machine Sanitization
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen. A brown colored substance and a dead bug, identified as a water bug or cockroach, were found on the floor between a reach-in refrigerator and freezer, along with a buildup of dust and debris on the floor and external surfaces of the units. The Dietary Supervisor was unaware of the presence of the debris and pest, while the Maintenance Supervisor confirmed the identification of the bug and acknowledged the dirty conditions. Pest control traps were present, but the area had not been adequately cleaned. The facility's ice machine was not sanitized according to the manufacturer's guidelines. The Maintenance Supervisor, responsible for cleaning the ice machine, reported using only a Nickel Safe Ice Machine Cleaner monthly, believing it served both as a cleaner and sanitizer. However, the manufacturer's instructions require a separate sanitizing step with a specific sanitizer, which was not being performed. The facility's policy also required monthly cleaning and sanitizing per the manufacturer's instructions, which was not followed. Additionally, baseboards under a kitchen sink were observed to be peeling away from the wall, creating an open crevice that could serve as an entry point for pests. Both the Dietary Supervisor and Maintenance Supervisor were aware of the issue, which had been noted in previous kitchen audits, but no action plan or repair had been implemented. Facility policies required regular sanitation inspections to ensure compliance with regulations, but the physical condition of the kitchen did not meet these standards.
Failure to Accurately Assess and Monitor Nutrition and Hydration Needs
Penalty
Summary
The facility failed to ensure comprehensive and accurate nutritional assessment and monitoring for a resident with significant medical needs, including moderate protein-calorie malnutrition, iron deficiency anemia, failure to thrive, and multiple pressure injuries. The Registered Dietitian (RD) did not reassess the resident's daily calorie, protein, and fluid needs after significant changes in condition, such as unplanned weight loss and worsening pressure injuries, despite facility policy and standard practice requiring such reassessment. The RD also did not evaluate whether the resident's food and fluid intake met her nutritional needs, nor did she review or utilize fluid intake logs to identify insufficient hydration, even when the resident had increased fluid needs due to draining wounds. The facility did not effectively monitor or document the consumption of oral nutrition supplements (ONS) provided to the resident. CNAs recorded total fluid intake from meal trays without specifying the type or amount of ONS consumed, making it impossible for the RD or nursing leadership to determine if the supplements were provided and consumed as ordered. Additionally, the facility delayed convening an interdisciplinary team (IDT) weight variance meeting to evaluate the effectiveness of the ONS intervention, during which time the resident continued to experience significant weight loss. The facility also lacked a variety of nutrition supplements to offer residents who required additional calories or protein, and did not offer alternative supplements when the resident refused the standard house nourishment shake. There was a lack of systematic monitoring and evaluation of the resident's hydration status. The RD did not review fluid intake documentation to compare actual intake to assessed needs, nor did she communicate concerns about inadequate fluid intake to the IDT or physician. The facility did not obtain the resident's beverage preferences to help improve fluid intake, and staff did not routinely monitor or discuss fluid intake logs in IDT meetings. As a result, the resident experienced further decline, including continued weight loss, poor wound healing, and a hospitalization for dehydration requiring IV fluids.
Failure to Offer Advance Directive Opportunity on Admission
Penalty
Summary
The facility failed to follow its own policy and procedure regarding advance directives (AD) for one resident. During an interview and review of the medical record for this resident, the Business Office Manager was unable to provide evidence that the resident or their responsible party had been offered the opportunity to formulate or decline an advance directive upon admission. The facility's policy requires that, on admission, staff determine if a resident has executed an advance directive and, if not, offer the opportunity to do so. There was no documentation in the resident's record to show that this process was followed.
Failure to Timely Replace Lost Resident Belongings
Penalty
Summary
The facility failed to ensure that two residents' personal belongings were replaced in a timely manner after being reported lost. One resident reported a missing watch that had been gone since December and had informed the social worker, who stated the facility would replace it. Despite this, the watch was not replaced, and the resident expressed upset over the delay. The resident's records confirmed the watch was listed among personal belongings at admission, and the resident was assessed as cognitively intact. Interviews with staff, including the Acting Activities Director and Administrator, confirmed the facility's policy to replace missing items within seven days, but this was not followed in the resident's case. Another resident reported a missing grey sweatshirt, which had sentimental value as it was a gift from her daughter. The resident stated she reported the missing item to housekeeping about a month prior, but it had not been replaced. Laundry staff indicated that, in the absence of social services staff, missing clothing items are now reported to their supervisor. The facility's policy states that reasonable care should be exercised to protect residents' property from loss or theft, but this was not adhered to in these instances.
Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a major decline in two or more MDS care areas, specifically unplanned significant weight loss and the development of a new wound. The MDS Coordinator acknowledged during interview and record review that a significant change MDS should have been completed at the same time as the quarterly MDS, as the resident had a notable decline in health status, including a 23% weight loss over six months and the appearance of new pressure ulcers. The quarterly MDS assessments documented an increase in the number of Stage 4 pressure ulcers and significant weight loss, yet no SCSA was initiated as required by regulation and facility policy. The resident's medical records indicated a history of moderate protein-calorie malnutrition, adult failure to thrive, and multiple wounds, including a Stage 4 pressure injury and trauma wounds. The interdisciplinary team and registered dietitian documented ongoing concerns about the resident's nutritional status, skin integrity, and the need for increased caloric and protein intake. Despite these documented declines and interventions, the required comprehensive assessment to address the significant change in the resident's condition was not completed, as confirmed by facility policy and staff interviews.
Inaccurate MDS Matrix and Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy and timeliness of the Minimum Data Set (MDS) Matrix for three out of eight sampled residents. For one resident, the matrix incorrectly indicated the use of anticoagulant medication, despite the resident having discontinued the medication several months prior, as confirmed by both the resident and a review of medical records. Another resident was incorrectly listed as receiving antibiotics, although the antibiotic therapy had been discontinued, and the resident confirmed not currently taking any antibiotics. The MDS Coordinator acknowledged that the matrix was not updated as required and admitted to not having updated it in time. Additionally, the facility failed to accurately code a resident's significant weight loss on both the MDS and the Resident Matrix. The matrix did not reflect excessive weight loss without a prescribed weight loss program, and the MDS inaccurately indicated that the resident was on a prescribed weight loss regimen. However, documentation and interviews with the Registered Dietitian confirmed that the resident was not on a weight loss program but was instead receiving nutritional interventions to address malnutrition and pressure ulcers. The MDS Coordinator confirmed the coding error and attributed it to the inaccurate MDS assessment. The facility's policy requires accurate and timely completion of all MDS assessments and supporting documentation, but the MDS Coordinator stated that updates were generally made weekly and admitted to not updating the matrix as expected. No specific policy was provided regarding the frequency or process for updating the Resident Matrix. The deficiencies resulted in inaccurate documentation for multiple residents, including an inaccurate quarterly MDS for one resident.
Failure to Provide Timely Assessment and Adherence to Aspiration Precautions During Choking Incident
Penalty
Summary
A resident with severe cognitive impairment, aphasia, and Alzheimer's disease experienced a choking episode in the dining room while being fed by a family member. Nursing staff present in the dining room did not immediately identify or address the choking incident, despite being responsible for supervision during mealtimes. The resident continued to cough and vomit, and was only attended to after a family member flagged down a nurse. The staff present, including the Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN), did not provide prompt intervention as required by facility policy and their training. Following the choking episode, a comprehensive assessment was not completed for the resident. The DSD performed only a limited abdominal assessment and did not evaluate for respiratory distress, airway obstruction, or oral cavity issues, which are necessary after such an event. The DSD delegated monitoring of the resident to a Hospitality Aid (HA), a non-nursing staff member whose role does not include direct care or clinical assessment. The incident was not reported to the resident's primary nurse, and the HA was only instructed to watch the resident for safety, which was not appropriate given the seriousness of the choking event. Additionally, the family member who routinely fed the resident was not provided with education on safe feeding techniques or aspiration precautions, despite the resident being on a pureed diet with nectar-thickened liquids and specific swallow strategies outlined by the speech therapist. Observations showed the family member feeding the resident large bites and thin liquids, contrary to the care plan and physician orders. The facility also failed to ensure that the resident received the prescribed thickened liquids, as the resident was observed consuming thin liquids during meals. These failures resulted in the resident's needs being unidentified and improper assessment and care during a choking episode.
Failure to Consistently Follow Pain Management Policy
Penalty
Summary
A deficiency occurred when the facility failed to follow its own pain management policy and procedure for a resident with chronic pain. The resident reported that, two weeks prior, a nurse instructed her to take a different medication instead of her regular pain medication, resulting in her experiencing significant discomfort for several hours without her usual pain relief. Review of the resident's physician orders indicated that Oxycodone HCL was prescribed for moderate pain and Acetaminophen for mild pain, with specific dosing instructions. However, the medication administration record showed that the resident received Acetaminophen on two occasions, despite her chronic pain status and the lack of explanation from the Assistant Director of Nursing (ADON) for this change in medication. The facility's pain management policy required collaboration among healthcare professionals and the resident to develop and implement appropriate pain interventions, as well as ongoing monitoring and revision as needed. The observed inconsistency in administering the prescribed pain medication, and the lack of documentation or rationale for substituting Acetaminophen for Oxycodone, led to the resident's pain not being consistently managed according to the established policy.
Failure to Ensure Proper Destruction and Documentation of Controlled Substances
Penalty
Summary
The facility failed to ensure accurate documentation and accountability for the destruction of controlled substances. During an observation in the Director of Nursing's office, a locked cabinet was found containing medications to be destroyed. Review of the Controlled Medication Destruction Log (MDL) for March and April revealed that entries for several controlled substances, including oxycodone, lorazepam, morphine, and hydrocodone, were not properly dated or signed, and lacked the required involvement of a licensed pharmacist. The Assistant Director of Nursing was unable to clarify these entries, and the Pharmacy Consultant confirmed she had not participated in the destruction of the medications in question. The nurse had incorrectly documented the destruction of narcotics without proper verification, and no concurrent destruction had occurred for those entries. The facility's policy and procedure required that the destruction of controlled substances be conducted in the presence of both a pharmacist and a registered nurse, with appropriate documentation including signatures of both witnesses and detailed information about the medication and its disposal. The reviewed records did not meet these requirements, as the destruction was not witnessed by a pharmacist and the necessary documentation was incomplete or missing. This failure resulted in a lack of accountability for the management and destruction of controlled medications.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure proper medication administration for three out of twenty-eight observed opportunities, resulting in an 11% medication error rate. During medication passes, a respiratory therapist did not instruct a resident to exhale fully or hold their breath as required when administering Combivent Respimat and Ellipta inhalers. The manufacturer's instructions for both inhalers specify that the patient should exhale fully before inhalation and hold their breath after inhaling the medication, but these steps were omitted during administration. The respiratory therapist acknowledged forgetting to provide these instructions during the observed medication passes. Additionally, a licensed vocational nurse administered Humalog insulin to another resident in the same abdominal site as the previous injection, contrary to the manufacturer's instructions to rotate injection sites to reduce the risk of lipodystrophy. Review of the medication administration record confirmed repeated use of the same injection site. The nurse admitted to forgetting to rotate the site during the observed administration.
Failure to Follow Menu and Fluid Restriction Orders
Penalty
Summary
The facility failed to follow the planned menu for a finger foods diet for one resident during lunch trayline. The resident's meal tray card and care plan indicated a finger food diet, which required foods to be cut into bite-sized pieces to allow for self-feeding and maintain independence and dignity. However, a whole piece of chocolate cake was served instead of being cut into smaller pieces as specified in the therapeutic diet spreadsheet and menu extension. The registered dietitian acknowledged that the menu was not followed and that she had not identified concerns with the finger foods menu in advance to provide proper instruction to dietary staff. Additionally, the facility did not ensure that the allotted fluid restriction for another resident was followed as ordered. The resident, who had end stage renal disease and was on a fluid restriction, had a care plan specifying a daily fluid limit with specific amounts to be provided by dietary and nursing. During review, it was found that the meal tray card did not provide the full amount of fluid allotted by dietary, resulting in the resident receiving less than ordered. The dietary supervisor confirmed that the resident had been receiving less fluid than prescribed and noted that the resident had expressed thirst. Both deficiencies were identified through observation, interview, and record review, and were supported by facility policies, job descriptions, and diet manuals that outlined the requirements for menu preparation, diet orders, and fluid restrictions. The failures were related to not following established dietary protocols and not providing the prescribed diet and fluids as ordered for the residents involved.
Failure to Obtain and Provide Resident Beverage Preferences for Hydration
Penalty
Summary
The facility failed to obtain and provide beverages consistent with a resident's preferences, as required to maintain proper hydration. During an interview and observation, the resident reported that she was only given the drinks available in the kitchen and that no one had asked her about her beverage preferences. The resident expressed a preference for drinks such as Pepsi, Kool-Aid, and pineapple juice, but these were not routinely offered. Review of the resident's records showed that while food preferences were updated, beverage preferences were not specifically documented, and the drinks provided were based on standard facility offerings rather than individualized choices. The resident had significant medical concerns, including a recent 21.3% weight loss over three months, decreased oral intake, multiple wounds (including a stage 4 pressure injury and trauma wounds), and a recent hospitalization for syncope with IV hydration. The facility's policies required that beverage preferences be obtained and reflected in the care plan, but the resident's care plan did not include beverage preferences or person-centered goals related to hydration. Staff confirmed that only routine beverages were offered and that there was no specific policy guiding the collection of beverage preferences beyond general food preferences.
Failure to Accurately Document Nutrition Supplement Intake in Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who had a physician's order for 4 ounces of house nourishment (HN shake) with breakfast. The electronic health record (EHR) did not contain documentation that this order was provided, and the amount of HN shake consumed was not separately recorded but instead included in the total fluid intake for breakfast. This practice impeded the interdisciplinary team's ability to assess the effectiveness of the nutrition intervention, as the specific intake of the HN shake could not be determined from the records. Additionally, a Certified Nursing Assistant (CNA) documented the resident's breakfast fluid intake as a late entry, recording the total fluids consumed at a time inconsistent with the actual meal time. The facility's policies and procedures did not provide clear guidance on how to document oral nutrition supplements, and staff training instructed CNAs to include these supplements in the overall fluid intake. As a result, the medical record did not accurately reflect the implementation of the nutrition order or the resident's actual intake, limiting the ability to monitor and evaluate the resident's nutritional status.
Failure to Follow Infection Control Practices During Insulin Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow established infection control practices while administering an injectable medication to a resident. During the administration of Humalog insulin using a quick pen to the resident's left lower abdomen, the LVN used her ungloved hand to uncap and dispose of the contaminated needle tip. The LVN acknowledged this action, stating she grabbed the needle without thinking and discarded it. Review of the facility's policy and procedure for subcutaneous insulin administration indicated that gloves should be worn, and the safety device should be engaged before discarding the syringe and needle in the appropriate disposal container. The observed practice did not align with the facility's infection control policy.
Failure to Administer Ordered Antipsychotic Medication Due to Unavailability
Penalty
Summary
The facility failed to administer an antipsychotic medication, Seroquel XR, as ordered by the physician for one resident. According to the Medication Administration Record (MAR) and physician's order, the resident was to receive 1.5 tablets of Seroquel XR 50 mg by mouth at bedtime. However, on multiple dates, the medication was not administered because it was not available, as documented in the progress notes. The MAR indicated missed doses on six separate days, with corresponding notes stating the medication was pending delivery and not available for administration. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the resident did not receive the ordered medication on the specified dates. The LVN acknowledged not administering the medication due to its absence in the medication cart and admitted to not notifying the pharmacy or the physician about the unavailability. The facility's policy required nursing staff to contact the prescriber if medication delivery was delayed or unavailable, but this procedure was not followed in this instance.
Failure to Enforce Identification Badge Policy
Penalty
Summary
The facility failed to adhere to its own policy and procedure regarding the wearing of identification badges by staff members. During an observation and interview, it was noted that two Certified Nursing Assistants (CNA 1 and CNA 2) were not wearing their required company-issued identification badges while on duty. CNA 1 admitted to forgetting her badge, while CNA 2 stated she had left hers in her car. The Director of Staff Development confirmed that it was the facility's practice for all staff to wear identification badges during their working hours. A review of the facility's policy, titled 'Identification Badges' and dated 2024, indicated that all employees are required to wear an identification badge during their hours worked.
Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
A deficiency occurred when a resident was not administered Rosuvastatin Calcium 20 mg as ordered by the physician for hyperlipidemia. The medication was not given on multiple dates throughout the month, as documented in the Medication Administration Record (MAR) and supported by progress notes indicating the medication was either pending delivery, on order, or not available. Despite these repeated missed doses, there was no evidence that the pharmacy was contacted for an expedited delivery or that the physician was notified about the ongoing unavailability of the medication. The facility's policy required nursing staff to contact the prescriber for direction when a medication delivery would be delayed or the medication was not available. However, this protocol was not followed, as confirmed by the Director of Nursing during an interview. The lack of timely communication and action resulted in the resident not receiving the prescribed medication as ordered.
Breach of Resident Confidentiality Through Unauthorized Screen Shot
Penalty
Summary
The facility failed to maintain the confidentiality of medical records for one resident when a screen shot of the resident's medical record was taken and shared via text message. This breach of confidentiality involved a screen shot that included the resident's picture and medical information such as birthdate, age, allergies, code status, and gender. The incident was reported by an anonymous complainant who indicated that a staff member at the facility was responsible for taking and sharing the screen shot. During interviews, the Administrator, Director of Nurses (DON), and Administrator in Training (AIT) confirmed that the screen shot contained sensitive resident information and acknowledged that taking such screen shots was against facility policy and HIPAA regulations. The facility's policy and procedure documents, including the Confidentiality and Non-Disclosure Agreement and the Protected Health Information (PHI) policy, emphasize that only authorized users should have access to resident information and that electronic protected health information should be safeguarded to prevent unauthorized access.
Failure to Refer Resident to Dermatologist as Ordered
Penalty
Summary
The facility failed to ensure that a resident was referred to a dermatologist as ordered by the physician, which could potentially delay treatment. The deficiency involved Resident 8, who had a dermatology consult ordered by the doctor on 11/25/24 for a generalized rash. However, as of 12/11/24, 16 days after the order, the Licensed Vocational Nurse/Infection Preventionist (LVN/IP) was unable to provide documentation that the referral process had been initiated. The Social Service Director (SSD) indicated that the nurses were responsible for placing the referral in the social service binder to schedule the appointment, and such referrals should be followed up within a week. The facility's policy stated that Social Services should collaborate with nursing staff to arrange for services ordered by the physician.
Failure to Report Scabies Outbreak to CDPH
Penalty
Summary
The facility failed to implement its policy and procedure for reporting communicable diseases when an outbreak of scabies was not reported to the California Department of Public Health (CDPH). Two residents were diagnosed with scabies, a contagious skin disease, but the outbreak was only reported to the county health department and not to CDPH. The facility's policy required the Infection Preventionist to notify the local, district, or state health department of confirmed cases of state-specific reportable diseases. However, the outbreak was not reported to CDPH because there was no confirmed skin scraping, despite the guidance indicating that an outbreak should be assumed following the diagnosis of a single case. Interviews with facility staff, including the LVN/IP and the Director of Nursing, revealed that the outbreak was not reported to CDPH due to the lack of confirmation. The Administrator acknowledged that a scabies outbreak should have been reported to CDPH when there were two or more cases, even if unconfirmed. The facility's failure to report the outbreak to CDPH resulted in the department being unaware of the situation, which was contrary to the guidance provided by the California Department of Public Health Prevention and Control of Scabies in California Healthcare Setting.
Failure to Implement Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that physician orders were implemented for a resident, which had the potential for the resident's injuries to worsen. The resident had specific orders to cleanse sutures on the back of the head with normal saline, monitor discoloration on various parts of the body for signs of worsening, and notify the doctor of any changes. These orders were to be carried out every shift or every day shift, depending on the specific treatment. However, during a review of the Treatment Administration Record (TAR) for November and December, it was found that the treatments were not administered on certain shifts, specifically on November 30th during the day and evening shifts, and on December 1st during the evening shift. The Director of Nursing (DON) confirmed that the treatments should have been documented on the TAR when administered, and acknowledged that there was no way to verify if the treatments were given when they were not documented. The facility's policy on Wound Treatment Management requires that wound treatments be provided according to physician orders and documented accordingly. The lack of documentation and potential failure to administer the treatments as ordered represents a deficiency in the facility's adherence to professional standards of quality care.
Inaccurate Fall Risk Assessment for Resident with Dementia
Penalty
Summary
The facility failed to ensure an accurate fall risk assessment for a resident, which had the potential to leave staff unaware of the resident's fall risk. The resident, who was admitted with a diagnosis of dementia, had a severe cognitive impairment as indicated by a BIMS score of 0. Following a fall incident, the resident complained of pain to the head and right shoulder and was sent to the hospital. However, the Fall Risk Evaluation (FRE) completed after the fall inaccurately scored the resident as having a low fall risk, with a score of 0, and noted the resident as oriented x3, with no falls in the past three months, and normal gait/balance. During an interview, the Director of Nursing (DON) acknowledged that the FRE was inaccurate, stating that the resident was not oriented x3, had a fall in the past three months, and had a shuffling gait. The DON indicated that the FRE score should have been greater than 10, reflecting the resident's actual fall risk. The facility's policy and procedure for fall risk assessment required completion upon admission, quarterly, or when a significant change is identified, including evaluating environmental hazards and individual risks.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The resident, who had Alzheimer's and dementia, was unable to verbalize the events due to cognitive impairment. However, a roommate with intact cognition witnessed the CNA cornering the resident, holding her down, and pulling her hair. The resident sustained multiple injuries, including bruises to the eyes, upper extremities, and a bald spot on the head, which were not present the previous day. The injuries were assessed by the Director of Nurses and other staff, who confirmed the fresh nature of the injuries and the resident's subsequent hospitalization for further evaluation. Another incident involved verbal abuse of a resident by a Licensed Vocational Nurse (LVN). The resident, who was cognitively intact, reported being called derogatory names such as "drug addict" and "pill seeker" by the LVN. This incident was corroborated by another resident and a staff member who witnessed the LVN pulling the resident's wheelchair away from the day room and verbally abusing him. The facility's policy clearly states that residents have the right to be free from verbal abuse, which was violated in this instance. The facility's investigation reports and interviews with staff and residents provided detailed accounts of the abuse incidents. The facility's policy on abuse prevention emphasizes the protection of residents from all forms of abuse, including physical and verbal, by anyone, including facility staff. Despite this policy, the incidents of abuse occurred, highlighting a failure in the facility's commitment to ensuring a safe environment for its residents.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the immediate assessment and notification of a resident's attending physician when a significant change in the resident's condition was observed. Specifically, a resident was found with multiple areas of discoloration, including the left inner corner of the eye, right eyebrow, bilateral upper extremities, and the back of the left thigh. These changes were initially reported by a CNA to an LVN at the beginning of the shift, but the LVN did not assess the resident or notify the attending physician as required by the facility's policy. The Director of Nurses confirmed that the injuries appeared fresh and were reported to the LVN by the CNA. However, the LVN did not take the necessary steps to assess the resident or inform the attending physician, mistakenly believing that not all changes needed to be reported. A full body assessment was only completed later in the day by another LVN, who documented the discolorations in the resident's progress notes. The facility's policy clearly states that any significant change in a resident's condition should be immediately assessed and reported to the attending physician, which was not followed in this case.
Failure to Communicate Discharge Instructions
Penalty
Summary
The facility failed to ensure that discharge instructions were communicated to the responsible party (RP) of a resident who was discharged home. The resident, who had a history of hemiplegia, hemiparesis, and severe pressure ulcers, was discharged without the RP being informed of the necessary care instructions. The discharge summary and instructions were not signed by the patient or a representative, indicating a lack of communication and acknowledgment of the care plan. The resident was discharged with a Brief Interview for Mental Status (BIMS) score of 4, suggesting severe cognitive impairment, which should have prompted the facility to communicate directly with the RP. However, the Licensed Vocational Nurse (LVN) responsible for the discharge only discussed the instructions with the resident, who was unlikely to understand them due to cognitive impairment. The Director of Nursing (DON) acknowledged that the LVN should have contacted the RP to discuss the discharge medications and wound care instructions. The RP was unaware of the resident's wound care needs, leading to the resident being readmitted to the hospital shortly after discharge due to an infected wound. The Social Service Director (SSD) also confirmed that home health services were not arranged prior to discharge, and the facility's policy required that the discharge summary include a description of the resident's ability to perform daily activities and special treatments. This oversight resulted in the RP being unprepared to care for the resident at home.
Failure to Follow Therapeutic Menu
Penalty
Summary
The facility failed to ensure that the therapeutic menu was followed for three of five sampled residents, leading to potential unmet nutritional needs. During a review of the Fall Menu, it was noted that the menu included chicken cacciatore, pasta, broccoli, cauliflower, salad, dessert, and milk for lunch. However, observations revealed that Resident 4, who was on a regular texture diet, received a mechanical soft texture chicken cacciatore because the kitchen ran out of the regular texture entree. Resident 4 did not recognize the meal and refused to eat it. Similarly, Resident 5, also on a regular texture diet, was served a mechanical soft texture entree due to the same shortage, and no salad was provided. Resident 6, who was on a chopped meats texture diet with a large portion, did not receive the salad that was supposed to be part of the meal, despite expressing a preference for it. Interviews with CNAs and the Dietary Supervisor confirmed these discrepancies, with the Dietary Supervisor acknowledging that the regular texture chicken cacciatore ran out and that the regular texture diet should have been served as planned. The facility's policy on menu planning, which requires menus to meet nutritional needs and comply with diet orders, was not adhered to in these instances.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to follow physician orders by not notifying the physician of elevated blood sugar levels for one of the residents. The resident's Order Summary Report indicated that the physician should be notified if blood sugar levels exceeded 300 mg/dl. However, a review of the Medication Administration Record showed multiple instances where the resident's blood sugar levels were above 300 mg/dl, yet there was no evidence of physician notification. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the physician should have been informed each time the resident's blood sugar exceeded the specified threshold. The facility's policy and procedure on diabetes management, dated 2020, required staff to incorporate physician-ordered parameters for monitoring and reporting blood sugar levels into the Medication Administration Record and care plan. Despite this policy, the facility did not adhere to the protocol, resulting in a failure to notify the physician of the resident's elevated blood sugar levels.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure medications were properly stored, resulting in unidentified pills being found in the bottom of medication carts. During an observation and interview, several loose pills were discovered in the drawers of medication carts 2 and 3. Licensed Vocational Nurse (LVN) 1 and LVN 2 both acknowledged that pills should not be loose in the bottom of the drawers. The Assistant Director of Nursing (ADON) was unable to identify the loose pills and confirmed that medications were not supposed to be loose in the drawers. A review of the facility's policy and procedure on Medication Labeling and Storage, dated 2001, indicated that medications and biologicals should be stored in the packaging, containers, or other dispensing systems in which they are received.
Failure to Implement Care Plan Post-Hospital Readmission
Penalty
Summary
The facility failed to implement a care plan for a resident after the resident was readmitted from the hospital. The hospital medical records were not requested in a timely manner, resulting in the facility being unaware of the resident's weight-bearing status and the need for a follow-up appointment. This oversight occurred after the resident had an unwitnessed fall, which led to a fracture in the right subcapital femur. The resident was observed ambulating with a four-wheeled walker, despite the hospital's discharge instructions recommending non-weight bearing. The interdisciplinary team met and determined that the resident's fall was related to poor balance and tripping over the walker. Although the care plan included interventions such as requesting medical records from the hospital, these records were not obtained until 11 days after the resident's return. Consequently, the orders for non-weight bearing and an orthopedic follow-up were not executed, placing the resident at risk for re-injury and delayed care.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
The facility failed to notify the physician of a change in condition for one of the residents who developed a rash. The rash was first identified on August 5th during a Shower Day Skin Inspection, which noted a skin problem with a rash all over the body. This was again documented on August 8th. However, the physician was not informed of the rash until August 13th, eight days after the initial identification. During an interview and record review on August 27th, the Infection Preventionist confirmed that the physician should have been notified when the rash was first identified on August 5th. The facility's policy and procedure for changes in a resident's condition, dated February 2021, requires that the nurse notify the resident's attending physician of any significant change in the resident's condition that will not resolve without intervention.
Failure to Complete Recommended Laboratory Tests
Penalty
Summary
The facility failed to adhere to its policy and procedure for laboratory testing for one of the sampled residents. Specifically, a laboratory test was not completed for a resident who was involved in an incident with another resident, resulting in a skin tear to the right lower eyelid. Following the incident, a psychiatric evaluation was conducted, and it was recommended that laboratory tests, including a complete blood count (CBC) and a comprehensive metabolic panel (CMP), be performed. However, upon review of the resident's clinical record, the Director of Nursing (DON) was unable to find documentation that these recommended laboratory tests were completed, acknowledging that they should have been done. The facility's policy requires staff to process test requisitions and arrange for tests based on the physician's orders, which was not followed in this case.
Infection Control and Surveillance Deficiencies
Penalty
Summary
The facility failed to follow infection prevention and control practices in accordance with CDC guidelines for all 92 residents. Specifically, a CNA did not perform hand hygiene after redirecting a resident with scabies, and the facility's infection preventionist admitted to not instructing staff on proper redirection techniques. Additionally, the central supply room, considered a clean room, was used to store medication carts that were not properly disinfected, and the laundry area was found to be in poor condition with overflowing trash bins, improperly maintained eye wash stations, and unlabeled clean linens stored inappropriately. The facility also failed to ensure proper surveillance for infections. The infection preventionist only conducted limited surveillance activities on donning and doffing PPE, with adherence rates as low as 25%. There was no documentation of analysis, tracking, or trending of the collected data, and no other surveillance activities, such as hand hygiene monitoring, were conducted. This lack of comprehensive surveillance compromised the facility's ability to identify and address infection control issues effectively. Furthermore, the facility did not develop or implement water management policies and procedures to prevent Legionella and other waterborne pathogens. The Director of Maintenance confirmed that no water testing had been conducted, and the facility lacked a water management program. The administrator acknowledged the absence of such policies and procedures, despite having received a risk management plan for Legionella control from an environmental consultant.
Failure to Ensure Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that physicians provided informed consents for four sampled residents before administering psychotropic medications. The deficiency was identified during interviews and record reviews, revealing that the informed consent forms (ICFs) for these residents were incomplete or improperly filled out. Specifically, the forms lacked actual signatures from responsible parties, and in some cases, the physician's signature was missing or dated after the medication had already been administered. Licensed Vocational Nurses (LVNs) were found to be explaining the risks, benefits, and alternatives (RBAs) to the residents' representatives instead of the physicians, which is against the facility's policy and procedure (P&P) requirements for informed consent documentation and physician responsibilities. For Resident 29, the ICFs for Latuda, Cymbalta, and Ativan were reviewed and found to be missing the actual signatures of the responsible party, with the nurse documenting that they had obtained informed consent. Similarly, Resident 35's ICFs for Abilify and Ativan were incomplete, lacking the name and signature of the responsible party, and the physician's signature was either missing or dated after the consent was supposedly obtained. Resident 72's ICFs for Buspirone, Depakote, and Ativan also had similar issues, with missing signatures and incomplete forms. Resident 143's ICFs for Sertraline and Trazodone were reviewed and found to be missing the name and signature of the responsible party, and the physician's signature was absent. The Medication Administration Record (MAR) indicated that Resident 143 had already received the medications before the informed consent was properly documented. The facility's P&P clearly states that it is the physician's responsibility to obtain informed consent and document it in the resident's health record, which was not adhered to in these cases.
Failure to Ensure Functional and Accessible Call Lights
Penalty
Summary
The facility failed to ensure that four of 46 sampled residents were assessed and provided with the appropriate call light type to call staff when needed. During observations, it was found that Resident 44's call light was on the floor, Resident 242's call light wire was not attached to the wall and was not within reach, and Resident 39's call light was on the oxygen concentrator and not working. Additionally, Resident 4's call light was not within reach. The Director of Maintenance confirmed that the call lights were not working and stated that residents should have a service call bell to call for assistance. Interviews with staff members, including a Certified Nursing Assistant and a Licensed Vocational Nurse, confirmed that call lights should be within reach at all times. The facility's policy and procedure on the resident call system indicated that residents should be provided with a means to call for assistance from their bed, toileting/bathing facilities, and the floor, and that the call system should remain functional at all times. The failure to ensure functional and accessible call lights had the potential for residents' needs not being met.
Failure to Ensure Advance Directives and Proper POLST Procedures
Penalty
Summary
The facility failed to ensure that 10 out of 13 sampled residents or their representatives were provided with information and allowed to formulate advance directives (ADs). During interviews and record reviews, it was found that several residents, including Residents 54, 80, 29, 143, 72, 36, 78, 45, 82, and 24, did not have completed ADs on file. Licensed Vocational Nurse (LVN) 3 and the Director of Nursing (DON) were unable to provide documentation that AD information was offered to these residents or their representatives. Additionally, some ADs were incomplete, missing signatures, or not properly filled out, as noted in the cases of Residents 36, 78, 45, 82, and 24. The facility's policy requires that residents be provided with written information about their right to accept or refuse medical treatment and to formulate an AD, but this was not consistently followed. The facility also failed to ensure that the Physician's Order for Life Sustaining Treatment (POLST) was properly ordered by the physician before being signed by the residents' representatives. In the cases of Residents 143 and 142, the POLST forms were signed by the residents' representatives without the necessary physician's order or signature. LVN 3 and LVN 2 admitted that the forms were signed by the representatives in the absence of the physician's order, which is against the facility's policy. The Order Summary Report for Resident 142 did not indicate that the physician had ordered the medical emergency treatment as per the resident's wishes. The facility's policy and procedure on advance directives, revised on a specified date, states that residents have the right to formulate an AD and that these directives should be honored in accordance with state law and facility policy. The policy also requires that the social services director or designee inquire about the existence of any written ADs prior to or upon admission and provide written information about the right to accept or refuse medical treatment. However, the facility did not adhere to these procedures, resulting in incomplete or missing ADs and POLST forms for several residents.
Failure to Provide Baseline Care Plan Summary Within 48 Hours
Penalty
Summary
The facility failed to ensure that two residents, Resident 142 and Resident 143, received a summary of their Baseline Care Plan (BCP) within 48 hours of admission. Resident 143, who was admitted with diagnoses including Cerebral Palsy and unsteadiness on her feet, did not have a completed BCP. During an interview and record review, it was found that the BCP was not signed, and neither the resident nor the resident representative had received the summary. Licensed Vocational Nurse (LVN) 1 confirmed that the BCP had not been given to Resident 143 or their representative. Similarly, Resident 142, who was admitted with metabolic encephalopathy and unsteadiness on feet and was Spanish-speaking, also did not have a completed BCP. During a concurrent interview and record review, it was revealed that the BCP was incomplete, and there was no signature indicating that the resident or their representative had received the summary. LVN 1 confirmed the BCP was not completed. The facility's policy and procedure for Baseline Care Plans require that a written summary be provided to the resident and representative within 48 hours of admission, which was not adhered to in these cases.
Lack of Competency Documentation for Staff
Penalty
Summary
The facility failed to provide documentation of competency and skill performance for six of eight sampled employees, including CNAs, an RNA, an RN, the ADON, and the IP. During interviews and record reviews, it was found that there were no competency evaluations or skills performance checklists in the employee personnel records (EPRs) for these staff members. The Director of Staff Development (DSD) acknowledged that CNAs are supposed to shadow another CNA during orientation but admitted that there were no competency assessments available for CNAs. Similarly, the EPRs for the RN, ADON, and IP lacked the required competency evaluations and skills performance checklists, which the DSD stated should be reviewed by the Director of Nursing and then filed in the EPRs. The facility's forms for Nursing Assistant Orientation & Competency Evaluation Nursing Skills Performance Satisfactory Completion (NAC) and Licensed Nurse Competency (LNC) were reviewed and found to include various skills and competency assessments that were supposed to be completed upon hire and annually. However, these forms were not found in the EPRs of the sampled employees. Additionally, the facility's Policy and Procedure (P&P) titled On-the-Job Training indicated that on-the-job training programs should be conducted to assist employees in performing their assigned tasks, with training records to be filed in the employee's personnel file. The lack of documentation of competency and skill performance for the sampled employees indicates a failure to ensure that staff are competent and skilled, as required by the facility's policies and procedures.
Failure to Label Opened Food Items and Replace Expired Ice Machine Water Filter
Penalty
Summary
The facility failed to ensure that opened food items were labeled with an expiration date and that the ice machine's expired water filter was replaced per the manufacturer's guidelines. During an observation in the dry food storage area, an opened bag of egg noodles was found without an opened date. Additionally, several spices and seasoning containers in the kitchen were opened without any opened or expiration dates. The Interim Dietary Supervisor and Registered Dietitian confirmed that the facility's policy requires labeling of opened food items with the date and expiration date, which was not followed in these instances. Furthermore, the ice machine's external water filtration system had an expired filter, which was last changed beyond the recommended six-month interval. The Director of Maintenance acknowledged that the filter was expired and mentioned that a new filter was on order. The facility's policy and the manufacturer's guidelines both indicate the necessity of regular maintenance and timely replacement of the water filter to ensure optimal performance. These lapses in following proper food storage and equipment maintenance protocols had the potential to affect the quality and safety of food and water provided to residents.
Inadequate Oversight of Infection Control and QAPI Programs
Penalty
Summary
The facility failed to ensure proper oversight of their Infection Prevention and Control Program (IPCP) and the Infection Preventionist (IP). This resulted in the removal of personal belongings, memorabilia, and clothing for five residents due to a scabies outbreak. The items were stored inappropriately in the laundry room, which was confirmed by the Housekeeping and Laundry Manager (HLM) and the IP. The Administrator and Director of Nursing (DON) were unaware of these actions, which were not based on physician orders but were decisions made by the IP to contain the infection. The Centers for Disease Control and Prevention (CDC) guidelines indicate that such extensive measures are unnecessary for scabies control, highlighting a lack of adherence to proper infection control protocols. The facility also failed to establish a water management program as part of their IPCP. During an interview, the Administrator admitted that the facility did not have Water Management Policies and Procedures in place, despite having received a Risk Management Plan for Legionella Control from an Environment Consultant. This lack of a water management program posed a potential risk for water-borne infections, indicating a significant oversight in the facility's infection control measures. Additionally, the facility did not develop and implement Quality Assurance and Performance Improvement (QAPI) policies and procedures. The Administrator provided a generic booklet titled 'QAPI Guidance, Performance Improvement Projects,' which was not specific to the facility and only served as guidance. This failure to establish a facility-specific QAPI framework put residents and staff at risk, as it did not address high-risk, high-volume, and problem-prone areas effectively. The lack of a robust QAPI program compromised the quality of care and services for all residents in the facility.
Failure to Provide Binding Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to provide the Binding Arbitration Agreement in simple, understandable language or in a language other than English. During an interview, the Business Office Manager (BOM) stated that the arbitration discussion typically occurs during admission and that the agreement is part of the admission packet. The BOM admitted that she explained the agreement to the best of her ability and knowledge, but the facility did not have a language-assistance service or the agreement form in any language other than English. Additionally, the BOM acknowledged that she could not explain every paragraph of the agreement form and that the facility lacked policies and procedures for entering into a Binding Arbitration Agreement. A review of the Center's for Medicare and Medicaid Services (CMS) recommendation on Binding Arbitration Agreements indicated that all agreements must be in plain language and explained to the resident or their representative in a language they understand. The facility's failure to comply with these recommendations was evident as they did not provide the agreement in a language other than English and did not have a language-assistance service. Furthermore, the facility could not provide a policy and procedure document for entering into Binding Arbitration Agreements when requested.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for one of eight sampled residents, specifically Resident 45. During an observation on April 16, 2024, at 9:19 a.m., multiple splatters of a brown substance were found on the wall and floorboards to the left of Resident 45's bed. In a concurrent observation and interview at 9:36 a.m., the Director of Nursing (DON) acknowledged that the room was not clean or acceptable and noted that the wall and floorboard appeared to have not been cleaned in a while. The facility's policy and procedure, dated August 2020, mandates that staff create a personalized, homelike atmosphere with attention to cleanliness and order, which was not adhered to in this instance.
Deficiencies in Grooming and Oral Care
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for Resident 4, resulting in the resident having long and dirty fingernails. During an observation, it was noted that Resident 4's fingernails on her left hand were long and had blackish discoloration underneath. Both a CNA and an LVN confirmed the condition of Resident 4's fingernails, and the facility's policy indicated that nail care should include daily cleaning and regular trimming to prevent infection and skin problems around the nail bed. However, it was revealed that nail care was only performed on Sundays, which contributed to the deficiency observed. The facility also failed to ensure that Resident 45 was assisted with oral care, leading to dental issues and/or tooth decay. During an observation, Resident 45's teeth were found to have dark discoloration and plaque buildup. Interviews with an LVN, a Clinical Resource Nurse, and the DON confirmed that Resident 45's dental health was poor, with visible cavities and plaque buildup. The resident's care plan indicated a need for total care with all activities of daily living, including oral hygiene, due to severe cognitive impairment. Despite this, the facility's staff only attempted oral care once per shift, which was insufficient to maintain proper oral hygiene for Resident 45.
Failure to Provide Activities Meeting Residents' Interests
Penalty
Summary
The facility failed to provide activity choices that met the interests and preferences of two residents, resulting in expressions of boredom and dissatisfaction. Resident 29 was observed sitting at the edge of the bed, stating there was nothing to do and expressing a desire for reading materials such as books, magazines, and newspapers. The Activities Director (AD) and Activity Assistant (AA) acknowledged that Resident 29 enjoyed reading and other activities but failed to ensure these materials were available. The resident's care plan indicated a preference for reading and social activities, but these were not adequately provided, leading to the resident's boredom and lack of engagement. Resident 87 expressed a love for playing the guitar and a desire to have musical instruments available. The resident's family had taken the guitar home, and the facility did not provide any musical instruments for residents. The AD and AA confirmed the resident's interest in music and acknowledged the importance of having a guitar. However, the resident's assessment did not reflect this interest, and the facility's policy on activity evaluation was not followed, resulting in the resident's dissatisfaction and lack of meaningful activities.
Failure to Follow Up on Hearing Aids for Residents
Penalty
Summary
The facility failed to ensure Social Services followed up on the status of hearing aids for two residents, leading to potential communication issues and loss of hearing abilities. Resident 29 reported having hearing problems and had an audiogram indicating moderately severe hearing loss in both ears, qualifying them for hearing aids under Medical. However, the Social Services Director (SSD) admitted to not having a log to track follow-ups and had not made any follow-up since January 2024. The facility's policy required staff to assist residents in obtaining services to replace lost or damaged hearing devices, but this was not adhered to in Resident 29's case. Similarly, Resident 36, who was observed not wearing hearing aids, reported being very hard of hearing and previously having effective hearing aids. The SSD reviewed Resident 36's audiogram from July 2023, which also indicated significant hearing loss qualifying for hearing aids under Medi-Cal. The SSD acknowledged that she should have followed up with the hearing aid company but failed to do so. The facility's policy mandated the social worker to assist residents in locating and utilizing resources for vision and hearing services, which was not followed in this instance as well.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly wound assessments were conducted for a resident with existing wounds. During an interview and record review, it was found that Resident 39, who was admitted with a wound on the left hand's first and second fingers, did not receive weekly wound assessments for four weeks in March. Only one wound assessment was documented on April 3, 2024. The Licensed Vocational Nurse confirmed the lack of weekly assessments, and the Director of Nursing acknowledged that weekly wound assessments should be performed for residents with wounds. The facility was unable to provide a policy and procedure related to weekly wound assessments upon request.
Failure to Administer Prescribed Contracture Treatment
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment for contractures in his left hand. During an observation, it was noted that the resident did not have a physician-ordered rolled-up washcloth in his hand. The resident's orders, dated several months prior, indicated that his left hand should be cleansed, patted dry, and a rolled-up washcloth placed in it every day. However, this treatment was not being carried out as observed on multiple occasions and confirmed by staff interviews. The Infection Preventionist (IP) and Restorative Nursing Assistant (RNA) both acknowledged that the treatment was not being administered as required. Further review of the resident's restorative nursing documentation revealed no records of the prescribed treatment being performed over a specified period. The facility's policy on Restorative Nursing Services, which aims to promote optimal safety and independence, was not adhered to in this case. The RNA stated that the treatment order was not in her iPad, which contributed to the oversight. This failure had the potential to worsen the resident's contracture condition.
Incomplete Post-Dialysis Monitoring Documentation
Penalty
Summary
The facility failed to ensure proper communication and coordination between the facility and the dialysis center, specifically regarding the assessment of dialysis access sites for two residents. During a review of the Nurses Dialysis Communication Record (NDCR) for Resident 39, it was found that post-dialysis monitoring was not documented on two separate dates. Licensed Vocational Nurse (LVN) 2 confirmed that these forms were incomplete and should have been filled out immediately upon the resident's return to the facility. Similarly, the NDCR for Resident 49 also lacked post-dialysis monitoring documentation on a specific date, which LVN 2 acknowledged should have been completed right away. The facility's policy and procedure for hemodialysis, dated 2023, mandates that the facility provide necessary care and treatment consistent with professional standards of practice, including ongoing assessment and monitoring for complications before and after dialysis treatments. The failure to complete the NDCR forms as required indicates a lapse in adhering to these standards, potentially compromising the residents' care and safety. This deficiency was identified through interviews and record reviews conducted by the surveyors.
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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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