Pacific Care Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3355 Pacific Place, Long Beach, California 90806
- CMS Provider Number
- 056007
- Inspections on file
- 38
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Pacific Care Nursing Center during CMS and state inspections, most recent first.
A resident with type 2 DM, severe protein-calorie malnutrition, and a documented stage 4 sacrococcygeal PU, who was dependent on staff for repositioning and had a high-risk Braden score, was not turned and repositioned at least every two hours as required by the care plan and facility policy. Observations showed the resident remained on the left side on a low air loss mattress with a wedge under the right buttock for over four hours. Staff interviews confirmed the resident could not turn independently and that licensed nurses and CNAs were responsible for ensuring q2h turning, consistent with the facility’s pressure ulcer prevention policy.
A resident with ESBL-positive UTI, cognitive impairment, incontinence, and need for substantial assistance with ADLs was placed on contact isolation per care plan and lab-confirmed results. Despite a posted contact isolation sign and facility policy requiring gown and gloves upon room entry, a CNA and an RN entered the resident’s room and handled the wheelchair with bare hands, without wearing an isolation gown or gloves. Both staff later stated they forgot the resident was on contact precautions. The IPN and DON confirmed that, given the ESBL status and contact precautions, staff should have performed hand hygiene and worn appropriate PPE to prevent cross contamination and potential spread of infection.
A resident with a gastrostomy tube experienced ongoing leakage and skin irritation at the stoma site, which was observed and documented by nursing staff over several months. Despite care plan instructions to notify the physician if healing did not progress, staff did not escalate the issue in a timely manner, resulting in the resident being transferred to a hospital for further evaluation and management.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Staff failed to follow infection control protocols during care and medication administration for three residents, including improper handling of linens, inadequate hand hygiene, incorrect perineal care technique, and contamination risks during g-tube and eye drop administration. These actions did not comply with facility policies and placed residents at risk of infection.
The facility did not ensure that care and services provided met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Staff did not use a communication board as required for a Spanish-speaking resident dependent on staff for all ADLs, resulting in ineffective communication about pain needs. Despite the care plan and facility policy mandating use of communication aids, an LVN communicated only in English, and the resident's pain was not properly assessed or addressed.
A resident did not receive the necessary care to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A resident with significant mobility and safety risks was left unattended in bed with the bed elevated and brakes unlocked prior to a transfer using a mechanical lift. Staff confirmed that the bed should have been in the lowest position with brakes locked, and the resident should not have been left alone, in accordance with the care plan and facility policy for high fall risk residents.
A resident with end stage renal disease, hydronephrosis, urinary retention, and diabetes had an indwelling urinary catheter and physician orders to monitor urinary output every shift. Staff interviews and record reviews showed that the catheter bag was not emptied and measured every shift as required, with documentation missing for multiple shifts. Nursing and supervisory staff confirmed the importance of this monitoring, but facility policy and physician orders were not consistently followed.
A CNA did not receive a required annual performance evaluation, with the last review documented several years prior. Both the DSD and DON confirmed that annual evaluations are necessary to assess staff competency and performance, but this process was not followed for the CNA.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not performed with the required accuracy.
The facility experienced repeat deficiencies in pharmacy services, quality of care, and infection control due to the QAA committee's failure to provide effective oversight and implement corrective actions. Despite having a QAPI program and relevant policies in place, the committee did not successfully address or resolve the previously identified issues.
The facility did not have a program in place to monitor antibiotic use, resulting in a lack of systematic tracking or evaluation of antibiotic prescribing and administration for residents.
The facility did not ensure that several staff members, including CNAs, an LVN, and the Director of Rehabilitation, were offered the COVID-19 vaccine or that their vaccination status was properly documented, as required by facility policy. Interviews confirmed that the Infection Preventionist Nurse did not maintain records of vaccine offers or declinations for these employees.
A resident with anxiety disorder and mild cognitive impairment experienced verbal abuse from an LVN during a medication-related discussion. The resident cursed at the LVN, who responded in kind, leaving the resident feeling unsafe. Another resident witnessed the incident, describing the LVN's response as aggressive. The LVN later resigned, and the DON confirmed the suspension for verbal abuse, acknowledging potential harm.
A facility failed to report a resident's left thigh swelling of unknown origin to state agencies within the required 24-hour timeframe, delaying the investigation by CDPH. The resident, with severe cognitive impairment and total dependence on staff, experienced this unusual occurrence, which was not reported promptly by the facility's staff, including the DON and ADM. The facility's policies require immediate or timely reporting of such incidents, which was not adhered to, potentially compromising resident safety.
A resident with a history of stroke experienced severe pain and slurred speech, indicative of a transient ischemic attack (TIA). Despite these symptoms and family concerns, the LTC facility delayed transferring the resident to a hospital, resulting in a missed opportunity for timely thrombolytic therapy. The resident was later diagnosed with an ischemic stroke and suffered permanent brain damage due to the facility's failure to follow emergency care protocols.
A resident with a history of threatening behavior verbally abused and threatened another resident in the dining room. Despite having a care plan addressing the behavior, the facility failed to initiate a Change of Condition to monitor the resident's behavior, leading to the incident. The facility's policies on abuse prevention and monitoring were not adequately followed.
A resident with a stage four pressure ulcer was not repositioned every two hours as required, leading to a deficiency in care. Despite a system where music played every two hours to remind staff, the CNA was busy with other duties and did not reposition the resident for four hours. The facility's policy and the resident's care plan both emphasized the importance of repositioning to prevent further skin breakdown.
A resident with a history of asthma and dementia showed respiratory symptoms, including a productive cough and wheezing, but was not tested for COVID-19 until two days later. Staff interviews revealed that the delay occurred because they waited for the Director of Staff Development to perform the test, despite all licensed nurses being trained to do so. The facility's infection control policy required timely testing to prevent disease spread.
A resident with hemiplegia and osteoarthritis was not offered alternative mobility options when their motorized wheelchair broke down. Despite having intact cognition and being dependent on staff for transfers, the facility did not provide a manual wheelchair or other alternatives, leading to the resident remaining in bed for almost a week. Staff interviews confirmed the lack of action, and the facility's policy on resident rights was not followed, putting the resident at risk for immobility and isolation.
The facility failed to prevent and manage pressure injuries in two residents. One resident developed Stage IV and Stage III pressure injuries due to inconsistent turning and repositioning, delayed nutritional assessment, and improper wound care. Another resident with an existing pressure injury was not consistently turned, as required by their care plan. Documentation was missing for several shifts, and the facility's pressure injury management policy was not followed.
A facility failed to provide ordered rehabilitative services for a resident, including speech therapy and the application of knee splints. The resident, with severe cognitive impairment and dependency on staff for daily activities, did not receive the prescribed speech therapy sessions for one week and lacked documentation for knee splint application over a two-week period. The Director of Rehabilitation Services and the DON confirmed these deficiencies, highlighting a failure to adhere to physician orders and facility policies.
A facility failed to ensure accurate documentation for a resident's pressure injury. The resident, with multiple health issues, had discrepancies in records regarding a pressure injury on the left lateral malleolus. While the MDS indicated intact skin, other reports described the injury differently, with some noting it as unstageable and others as Stage III. The DON acknowledged the error and noted the need for accurate records, as per facility policy.
Two residents engaged in a verbal and physical altercation, which was not reported to the Administrator and CDPH as required. A CNA witnessed the residents throwing oatmeal, and an RNA reported a verbal altercation involving racial slurs. The Administrator did not report the incidents, considering them as roommate incompatibility. Both residents were capable of making decisions, and the facility's policy required reporting such incidents to the Ombudsman and CDPH.
A Hemodialysis Nurse and Technician failed to follow infection control protocols while caring for two residents with Candida Auris. They did not use hand hygiene or wear appropriate PPE, leading to potential cross-contamination. Observations showed the staff touching residents and equipment with bare arms and exposed uniforms. Interviews confirmed the importance of adhering to infection control policies to prevent infection spread.
Two residents with cognitive abilities engaged in a verbal altercation, with one using racial slurs, which was not investigated by the facility. The Administrator was informed of the incident but did not conduct an investigation, citing it as a roommate incompatibility issue. The facility's policy requires all incidents to be investigated and reported to CDPH, which was not done, resulting in a deficiency.
A facility failed to re-admit a resident after hospitalization, despite the resident being cleared to return by the hospital. The resident, who required significant assistance and had a gastrostomy and schizoaffective disorder, was not readmitted due to concerns about the facility's ability to meet psychosocial needs. The facility had available beds but did not comply with its policy to readmit Medicaid residents requiring SNF services.
The facility failed to ensure safe food storage and preparation, affecting 89 residents. An ice machine had black residue, indicating improper cleaning, risking bacterial contamination. A dented can of applesauce was improperly stored with ready-to-use cans, risking botulism. Facility policies on cleaning and handling damaged cans were not followed.
The facility failed to ensure the Infection Preventionist Nurse (IPN) attended and participated in QAPI committee meetings, as required. The IPN did not sign in or present infection control reports during meetings, and the facility lacked a policy for their QAPI Program. The ADM and IPN were new, and the previous IPN had resigned, contributing to the oversight.
The facility failed to implement proper infection control practices, including undated PIVs, unchanged ventilator tubing, and improper nebulizer storage, increasing infection risks for residents. Incorrect isolation precautions and improper hand hygiene during wound care further compromised resident safety. Additionally, expired and unlabeled food in the resident fridge posed a risk of foodborne illness.
Two residents in an LTC facility did not receive adequate fingernail care, leading to potential health risks. One resident, with severe cognitive and physical impairments, had long nails causing redness in his contracted hand, despite family notifications to staff. Another resident, requiring maximum assistance, was repeatedly observed with untrimmed, dirty nails. Staff interviews revealed that CNAs were responsible for nail care, but facility policies for daily cleaning and weekly trimming were not followed.
A resident with cerebellar ataxia and parkinsonism was observed unable to reach their call light, which was on the floor, despite being cognitively intact and requiring substantial assistance. Staff interviews and facility policy confirmed that call lights should be within reach, but this was not adhered to, impacting the resident's ability to request assistance.
A resident with schizophrenia and other conditions experienced increased yelling, but the facility staff failed to notify the psychiatrist as required. Despite a PCC's recommendation for a psychiatric evaluation, there was no documentation of contact with the psychiatrist. Interviews with staff confirmed the oversight, which contradicted the facility's policy for timely communication with primary care providers.
A facility failed to submit a complete quarterly MDS for a resident to CMS due to incomplete sections on mood and behavior, and missing signatures. The resident, who was dependent on staff for daily activities, had multiple diagnoses including quadriplegia and muscle weakness. Interviews with the MDS Nurse and DON highlighted the importance of timely MDS completion for optimal care and billing, as delays can affect care quality.
The facility failed to develop person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. One resident required maximal assistance with ADLs and had unclear speech, another needed oxygen therapy without a care plan, and a third resident with quadriplegia lacked a comprehensive care plan. These omissions risked compromising the quality of care provided.
A resident with severe cognitive impairment and multiple health issues was not consistently receiving continuous oxygen therapy as ordered. Observations showed the nasal cannula was often misplaced, and staff confirmed the resident frequently removed it. There was no care plan addressing this behavior, contrary to facility policy.
A resident with multiple diagnoses, including fibromyalgia and osteoarthritis, experienced unrelieved severe pain due to the facility's failure to reassess pain levels and administer additional medication as needed. Despite receiving routine pain medications and non-pharmacologic interventions, the resident reported pain levels of 7-8 out of 10. Staff admitted to not documenting pain reassessments or notifying the physician, contrary to the facility's pain management policy.
A facility failed to provide a dialysis emergency kit at the bedside for a resident requiring dialysis services. Despite the resident's need for hemodialysis and anticoagulant therapy, observations and interviews revealed the absence of the necessary e-kit, which is crucial for managing potential bleeding from the dialysis access site. Staff confirmed the requirement for the kit and acknowledged the risk of delayed intervention.
A facility failed to document the administration of controlled substances for a resident, leading to discrepancies in medication records. The resident, with fibromyalgia and osteoarthritis, was prescribed Pregablin and Tramadol. An LVN admitted to administering these medications without proper documentation, contrary to facility policy. This oversight was confirmed through interviews and record reviews, highlighting the importance of immediate documentation to prevent errors and discrepancies.
A facility failed to maintain a medication error rate below five percent due to several deficiencies. An LVN administered an incorrect dose of Ferrous Sulfate to a resident without checking g-tube placement or elevating the head of the bed as required. Another LVN did not disinfect an insulin vial before administering it to a resident. These actions were against the facility's policies and posed risks of overdose, infection, and aspiration.
The facility failed to manage and label medications properly, with expired items like Banatrol Plus and ultrasound gel found in storage, and unlabeled medications on a cart. A resident's Artificial Tears were not labeled, risking incorrect administration. Staff interviews confirmed these items should have been discarded or labeled, but facility protocols were not followed.
A resident with severe cognitive impairment and ventilator dependence aspirated and vomited during feeding, but the facility failed to notify the physician or NP immediately. This delay in communication led to a delay in treatment and transfer to a hospital for further evaluation. Staff interviews revealed a lack of follow-up and a missing policy on notifying physicians of changes in condition.
A resident with acute respiratory failure and ventilator dependence had their ventilator settings changed without a physician's order, contrary to facility policy. Despite abnormal respiratory rates and NP recommendations, the resident's transfer to a GACH was delayed by RNS, who believed the resident was stable. The DON confirmed the need for transfer based on the NP's advice and the resident's condition.
A facility failed to implement appropriate seizure precautions for residents diagnosed with epilepsy and seizure disorders, leading to a serious deficiency. One resident with epilepsy and systemic lupus erythematosus was not identified as at risk for seizures upon admission and lacked necessary precautions such as padded side rails and a low bed position, resulting in a fall and head injury during a seizure. Additionally, two other residents with seizure disorders were found without adequate seizure precautions, including unpadded side rails and insufficient monitoring. The facility also lacked a policy and procedure for managing residents with seizure diagnoses, contributing to the deficiency.
The facility's QAA and QAPI committees failed to have a policy for managing residents with seizures, convulsions, and epilepsy, leading to a lack of seizure precautions for 24 residents. Interviews and record reviews revealed that residents at risk for seizures were not properly identified or managed, placing them at risk for falls and injuries. The facility's QAPI committee was focused on other priorities and had not addressed seizure management and prevention.
Failure to Reposition High-Risk Resident With Stage 4 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer prevention and care by not turning and repositioning a resident with an existing stage 4 pressure ulcer at least every two hours as required. The resident had multiple risk factors, including type 2 DM without complications, severe protein-calorie malnutrition, and a documented stage 4 PU to the sacrococcyx measuring 5.7 cm x 3.6 cm x 2.5 cm. The resident’s MDS showed he was dependent on staff for rolling from left to right, and his Braden Scale score of nine indicated high risk for pressure ulcer development. The resident’s care plan documented an alteration in skin integrity with an actual stage 4 pressure injury related to immobility and included interventions to turn and reposition at least every two hours and to use pillows as repositioning devices. Despite these documented needs and interventions, observations on multiple occasions the same day showed the resident lying on a low air loss mattress positioned on his left side with a wedge under his right buttock, without evidence of being turned or repositioned for over four hours. CNA 1 stated the resident could not turn himself and relied on staff to assist with turning and repositioning at least every two hours to prevent skin breakdown. LVN 1 stated that the treatment nurse and charge nurses were responsible for ensuring residents were turned and repositioned every two hours and as needed, and the DON stated licensed nurses were responsible for making sure CNAs turned residents every two hours. The facility’s policy on prevention of pressure ulcers required residents in bed to have their position changed at least every two hours or more frequently as needed, which was not followed in this case.
Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff failed to implement required contact isolation precautions for a resident with an ESBL-positive urinary tract infection. During an observation in the resident’s room, a CNA and an RN were present without wearing an isolation gown or gloves, despite a contact isolation sign posted outside the room. Both staff members were observed holding the resident’s wheelchair with bare hands while preparing to transfer the resident back to bed. In subsequent interviews, the CNA and RN each stated they had forgotten the resident was on contact isolation and acknowledged that staff should wear an isolation gown, gloves, and mask before entering the room when a resident is on contact precautions. Record review showed the resident had been admitted and readmitted to the facility with diagnoses including UTI, ESBL, depression, and COPD. The MDS indicated the resident had moderately impaired cognitive skills and required substantial/maximal assistance with transfers, bathing, and toileting, and was incontinent of urine. The resident’s care plan, dated two days prior to the observation, documented that the resident was on isolation precautions related to ESBL, with interventions including maintaining contact isolation precautions. An SBAR form and urine culture dated the same day confirmed ESBL in the urine and that the physician had been notified. The Infection Preventionist Nurse and DON both stated that, based on the resident’s ESBL status and facility policy on transmission-based precautions, staff entering the room should perform hand hygiene and wear gown and gloves to prevent cross contamination, and that not practicing contact precautions could cause spread of infection to other residents and result in an outbreak. The facility’s written policy on transmission-based precautions required gown and gloves upon entering rooms of residents on contact precautions.
Failure to Timely Address G-Tube Leakage and Notify Physician
Penalty
Summary
A resident with a gastrostomy tube (G-tube) experienced continuous leakage of tube feeding formula around the stoma site from January 2025 to the present. Observations and interviews revealed that the leakage was noted by nursing staff, with visible leaking through the G-tube dressing and increasing redness and size of the affected area. The resident, who had diagnoses including gastrostomy status, dysphagia, and tracheostomy, was totally dependent on staff for all activities of daily living and had severely impaired cognitive skills. Despite ongoing documentation of the leakage and skin changes in weekly assessments, there was a lack of timely follow-up and communication with the physician regarding the persistent issue. The care plan for the resident indicated that the physician should be notified if there was no progress in healing or signs of decline related to the G-tube site. However, staff interviews and record reviews confirmed that the leakage persisted for several months without adequate escalation or intervention. The Assistant Director of Nursing and other staff acknowledged that the evaluation and management of the G-tube site should have occurred earlier, and that licensed nurses should have reported abnormal changes to the physician as per facility policy. The resident was eventually transferred to a general acute care hospital for evaluation and management of the leaking G-tube.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Follow Infection Control Precautions During Resident Care and Medication Administration
Penalty
Summary
Multiple infection control deficiencies were observed involving three residents. For one resident with a history of multiple drug-resistant organisms and on enhanced barrier precautions, a CNA was seen placing a wet towel on a dirty chux, cleaning the resident’s rectum from back to front with the same towel, and returning a pillow and bed linen that had fallen on the floor to the resident’s bed. The CNA also failed to change gloves or perform hand hygiene after providing perineal care and did not remove personal protective equipment before leaving the resident’s room. These actions were confirmed by both the CNA and a treatment nurse present during the incident, who stated that proper procedures were not followed, including the use of clean linens and correct hand hygiene practices. Another resident, who was dependent on staff for all activities of daily living and received medications via a gastrostomy tube, was involved in an incident where an LVN prepared and administered medications using a syringe. The LVN left the resident’s bedside with the used syringe, walked to the medication cart, and then returned to continue medication administration with the same syringe, exposing it to environmental contamination. The LVN acknowledged that this practice was incorrect and could lead to contamination, and the DON confirmed that such actions increase the risk of infection. A third resident, who required assistance with activities of daily living and was prescribed artificial tears, was observed receiving eye drops from an LVN who did not perform hand hygiene after preparing medications, before donning gloves, or prior to administering the eye drops. The LVN later stated that hand hygiene should have been performed to prevent contamination and infection. Facility policies reviewed indicated that hand hygiene is required before and after direct resident care, after glove removal, and before medication administration, but these protocols were not followed during the observed incidents.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff, or detailed events leading to the deficiency.
Failure to Use Communication Board for Non-English Speaking Resident
Penalty
Summary
Staff failed to use a communication board as required by the care plan for a resident whose primary language is Spanish and who was dependent on staff for all activities of daily living. The resident had a history of cerebrovascular accident, tracheostomy with ventilator dependence, and fluctuating capacity to understand and make decisions. During an observation, the resident was seen grimacing and expressing pain, but the nurse communicated only in English and did not use the communication board, resulting in the resident not understanding the nurse and her pain needs not being effectively addressed. Interviews with staff confirmed that the communication board was not used during the pain assessment, despite it being part of the resident's care plan and facility policy. The nurse supervisor and DON acknowledged that staff are trained to use the communication board and that failure to do so can result in unmet resident needs. Facility policy also required the use of communication aids for residents assessed to need them.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where such decline was due to a documented medical reason. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Lock Bed Brakes and Provide Supervision During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of intracranial hemorrhage, cervical osteomyelitis, cervical discitis, and cervical spondylolisthesis was left unattended in bed prior to transfer using a mechanical lift. The resident's care plan identified poor safety awareness, a tendency to raise the bed to a high position, generalized muscle weakness, and a high risk for falls and injury, requiring fall precautions, frequent visual checks, and safety measures during transfers. On observation, the resident was found lying flat in bed with the bed elevated, side rails down, and the brakes at the foot of the bed not locked. Two wheelchairs were blocking the entrance to the room, and the resident's Foley catheter bag was on the bed next to her. Staff interviews confirmed that the bed brakes were not locked prior to transfer and that the bed should have been in the lowest position to prevent falls. The care plan and facility policy required maintaining the bed in the lowest position and locking brakes for high-risk residents. Staff acknowledged that the resident should not have been left unattended with the bed elevated and brakes unlocked, as this could result in a fall. The facility's policy also emphasized keeping the environment free of unnecessary obstacles and increasing supervision for residents at high risk for falls.
Failure to Monitor and Document Urinary Catheter Output as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, as required by professional standards and the resident's physician order. The resident, who had diagnoses including end stage renal disease, hydronephrosis, urinary retention, and diabetes mellitus, was dependent on staff for all activities of daily living and had a physician order to monitor urinary output every shift. The care plan also indicated the need to monitor intake and output every shift due to the resident's risk for urinary tract infection (UTI). However, interviews and record reviews revealed that the resident's urinary catheter bag was not being emptied and measured every shift as ordered. The resident reported that the bag was only emptied in the mornings and afternoons, and documentation of urinary output was missing for multiple shifts across several days. Staff interviews confirmed that the resident's urinary output should have been monitored, emptied, and measured once per shift, and that this was important for assessing urinary retention and preventing complications. The Medication Administration Record (MAR) lacked documentation of urine output in milliliters for several shifts, and both nursing and supervisory staff acknowledged the importance of this monitoring for a resident on dialysis with an indwelling catheter. The facility's policy required recording intake and output for residents with indwelling catheters or when ordered by a physician, but this was not consistently followed for the resident in question.
Missed Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to conduct an annual performance evaluation for a Certified Nursing Assistant (CNA) who was hired in 2010, with the last documented evaluation occurring in 2021. During a review of the CNA's employee file, it was found that no performance evaluation had been completed for several years, contrary to facility policy and job description requirements. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that annual evaluations are expected to assess job performance, identify areas for improvement, and ensure staff competency. The absence of a current evaluation meant the facility did not assess the CNA's skills and abilities as required.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Repeat Deficiencies Due to Ineffective QAA Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the plan of correction for deficiencies identified during the most recent recertification survey in 2024. This failure resulted in repeat deficiencies in the areas of pharmacy services, quality of care, and infection control. During a review of the facility's Statement of Deficiencies, it was found that these issues persisted despite the existence of a QAPI program intended to monitor and improve quality standards. An interview and record review with the Administrator revealed that although the QAPI program was ongoing and designed to analyze data and identify concerns, the Administrator, who had only recently started at the facility, was unsure why the deficiencies were repeated. The facility's policy stated that the QAPI committee was responsible for identifying and addressing care and quality issues and implementing action plans, but the repeat deficiencies indicated that these processes were not effectively carried out.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program indicates that antibiotic prescribing and administration were not being systematically monitored or assessed by the facility staff.
Failure to Document and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that five sampled employees, including several CNAs, an LVN, and the Director of Rehabilitation, were offered the COVID-19 vaccine as required. Interviews with the Infection Preventionist Nurse (IPN) revealed that while she is responsible for offering and documenting immunizations, there was no documentation showing that these employees were offered the COVID-19 vaccine or that they declined it. The IPN stated that she provides education and re-offers the vaccine, and if declined, employees are supposed to sign a declination form. However, she acknowledged that she did not have documentation of these offers or declinations for the sampled staff. A review of the facility's Coronavirus Vaccine Policy indicated that COVID-19 vaccinations are to be offered to all staff and residents, with documentation maintained for all individuals regarding their vaccination status. The Director of Nursing confirmed that the IPN is expected to document when staff are offered the vaccine, particularly upon hire. The lack of documentation and failure to ensure the vaccine was offered to these employees constituted a deficiency in following the facility's own policy and regulatory requirements.
Verbal Abuse Incident Involving LVN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Licensed Vocational Nurse (LVN). The incident involved a resident with a diagnosis of anxiety disorder, who was mildly cognitively impaired. The resident requested to speak with the LVN about her medication, expressing concerns about not feeling right and wanting to discuss potential changes with her physician. During this interaction, the resident cursed at the LVN, who then responded by cursing back at the resident. This exchange left the resident feeling unsafe and triggered, as she was seeking assistance with her medication. The incident was witnessed by another resident, who confirmed the LVN's lack of patience and empathy, describing the response as aggressive and brutal. The LVN admitted to cursing back at the resident and expressed regret over the incident, which led to her resignation. The Director of Nursing confirmed the LVN's suspension for verbal abuse, acknowledging the potential for mental or emotional harm to the resident. The facility's policy on residents' rights clearly states that residents have the right to be free from mental and physical abuse.
Failure to Timely Report Unusual Occurrence
Penalty
Summary
The facility failed to adhere to its abuse reporting and prevention policy by not reporting an unusual occurrence involving a resident's left thigh swelling of unknown origin to the appropriate state agencies within the required 24-hour timeframe. This incident involved a resident who was admitted with multiple diagnoses, including renal dialysis dependence, muscle contractures, and severe cognitive impairment, making them totally dependent on facility staff for all activities of daily living. The delay in reporting this unusual occurrence resulted in a postponed investigation by the California Department of Public Health (CDPH), potentially compromising the safety of the resident and others with similar vulnerabilities. Interviews with facility staff, including a Registered Nurse Supervisor (RNS), the Director of Nursing (DON), and the Administrator (ADM), revealed a lack of timely action in reporting the incident. The RNS acknowledged the necessity of immediate reporting within a two-hour window for witnessed abuse incidents, while the DON admitted that the initial reporting should have occurred on the same day the swelling was discovered. The ADM confirmed that the incident was reported late, as the notification to the State Survey Agency occurred three days after the discovery of the swelling. The facility's policy and procedure documents, including the Abuse Reporting and Prevention policy and the Unusual Occurrence Reporting policy, clearly outline the requirements for reporting incidents of unknown origin and unusual occurrences. These policies mandate immediate or timely reporting to the Ombudsman and the Department of Public Health, depending on the severity of the incident. The facility's failure to comply with these policies resulted in a delay in addressing the resident's condition and ensuring their safety, as well as the safety of other residents in similar situations.
Delayed Transfer Leads to Resident's Stroke
Penalty
Summary
The facility failed to ensure timely transfer of a resident with a history of acute stroke to a general acute care hospital (GACH) when the resident exhibited symptoms indicative of a transient ischemic attack (TIA). The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, reported severe pain in the left arm and slurred speech, which were not promptly addressed by the facility's staff. Despite the resident's family member expressing concerns and requesting a transfer, the facility delayed the transfer, resulting in the resident not receiving timely thrombolytic therapy. The report highlights several failures in the facility's response to the resident's condition. The Licensed Vocational Nurse (LVN) did not assess the resident when the Certified Nursing Assistant (CNA) reported the resident's severe pain and feeling of not being right. Furthermore, the Nurse Practitioner (NP) did not order an immediate transfer to the GACH, despite being informed of the resident's symptoms. The facility's staff did not follow the facility's policy and procedure for emergency care and change in condition, which required thorough assessment, physician notification, and immediate intervention. The delay in transferring the resident to the GACH resulted in a five-hour delay from the time the resident first reported symptoms of a TIA. This delay led to the resident being diagnosed with a left frontal lobe ischemic stroke and suffering permanent brain damage. The facility's failure to act promptly and follow established protocols contributed to the resident's inability to receive necessary medical treatment within the critical time window.
Failure to Monitor Resident with Abusive Behavior
Penalty
Summary
The facility failed to protect a resident from verbal abuse and threats by another resident. Resident 1, who has schizophrenia, diabetes, muscle weakness, and chronic kidney disease, was verbally abused and threatened by Resident 2 in the dining room. Resident 2, who has disseminated intravascular coagulation, muscle weakness, and acute kidney failure, approached Resident 1 and threatened to kill him, while also ramming his wheelchair into Resident 1's wheelchair. The incident was witnessed by a Restorative Nurse Assistant, who reported that Resident 2 expressed a willingness to be expelled from the facility. Resident 1 confirmed the incident, stating that Resident 2 was angry about Resident 1's interaction with another resident. The facility's Licensed Vocational Nurse noted that Resident 2 had a history of threatening behavior, which was documented in a care plan, but a Change of Condition was not initiated to monitor Resident 2's behavior more closely. The facility's policy on abuse prevention requires monitoring of residents with behaviors that may lead to abusive situations. However, the facility did not adequately monitor Resident 2's behavior, resulting in the incident. The facility's policy on Change of Condition also mandates thorough assessment and physician notification for changes in a resident's condition, which was not followed in this case.
Failure to Reposition Resident Every Two Hours
Penalty
Summary
The facility failed to ensure that a resident was turned every two hours as care planned, which is crucial to prevent the progression of a pressure injury. The resident, who was dependent on staff for various activities and had a stage four pressure ulcer, was not repositioned for four hours on a specific day. This lapse was identified when the resident's daughter reported the issue to the Registered Nurse Supervisor (RNS), who then assisted in changing and repositioning the resident. The facility's policy and the resident's care plan both indicated the necessity of turning and repositioning every two hours to prevent further skin breakdown. Interviews with staff, including the Treatment Nurse/Licensed Vocational Nurse (TX/LVN), Certified Nursing Assistant (CNA), and the Director of Nursing (DON), confirmed the requirement for repositioning every two hours. The facility had a system in place where music played every two hours to remind staff of this task. However, on the day in question, the CNA was occupied with other duties and did not respond to the reminder. The failure to adhere to the care plan and facility policy resulted in a deficiency related to the resident's care.
Delayed COVID-19 Testing for Symptomatic Resident
Penalty
Summary
The facility failed to adhere to infection control measures by not performing a timely COVID-19 test on a resident who exhibited symptoms of a respiratory illness. The resident, who had a history of asthma, unspecified dementia, and previous COVID-19 infection, showed signs of respiratory distress, including a productive cough and wheezing, on November 16, 2024. Despite these symptoms, the COVID-19 test was not administered until two days later, on November 18, 2024. This delay in testing was noted during interviews with various staff members, including a Licensed Vocational Nurse and the RN Supervisor, who were aware of the resident's condition but did not initiate immediate testing. The Infection Preventionist Nurse and the Director of Staff Development both acknowledged that the facility's protocol required testing for COVID-19 when residents displayed symptoms such as cough and congestion. However, the test was delayed because staff waited for the Director of Staff Development to perform it, despite all licensed nurses being trained to conduct the test. The Director of Nursing confirmed that staff should have acted promptly without waiting for the Infection Preventionist Nurse. The facility's policy on infection control emphasized the importance of early identification of communicable diseases to prevent their spread, which was not followed in this instance.
Failure to Provide Alternative Mobility Options for Resident
Penalty
Summary
The facility failed to ensure that a resident, who relied on a motorized wheelchair for mobility, was offered an alternative means to get out of bed when the motorized wheelchair broke down. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease and osteoarthritis, was dependent on staff for transfers and had intact cognition. Despite the resident's ability to understand and make decisions, the facility did not offer a manual wheelchair or other alternatives, such as a Geri chair, to facilitate the resident's mobility. Interviews with staff, including a CNA, Maintenance Supervisor, LVN, and RN Supervisor, revealed that the resident had not been out of bed for almost a week due to the broken motorized wheelchair. The Maintenance Supervisor confirmed that the facility did not have a replacement motorized wheelchair and was waiting for repairs. The RN Supervisor acknowledged that the resident had not used a wheelchair for eight days and confirmed that alternative options were available but not utilized. The lack of documentation regarding the resident's refusal to use a manual wheelchair further highlighted the facility's oversight. The Director of Nursing confirmed the absence of documentation in the resident's chart about any refusal to use a manual wheelchair and stated that the staff should have offered alternative seating options. The facility's policy on resident rights emphasized the need to accommodate residents' needs and preferences, which was not adhered to in this case. This oversight put the resident at risk for immobility and feelings of isolation and sadness.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to prevent the development and worsening of pressure injuries in two residents. Resident 2, who was admitted with intact skin, developed a Stage IV pressure injury on the left lateral malleolus and a Stage III pressure injury on the right lateral malleolus. The facility did not implement the care plan to turn and reposition Resident 2 every two hours, as documented evidence was missing for several shifts. Additionally, the Registered Dietician did not assess Resident 2's nutritional needs for pressure injury healing until 23 days after it was recommended, and the wound care recommendations were not properly followed, as the wound was not cleansed with Normal Saline before applying Betadine. Resident 12, who was admitted with an unstageable pressure injury to the sacrococcyx area, also did not receive consistent turning and repositioning every two hours as required by the care plan. Documentation was missing for several shifts, and Resident 12 complained about not being turned regularly during a Resident Council meeting. The facility's policy and procedure for pressure injury management, which included turning and repositioning residents every two hours, was not consistently implemented. The deficiencies in care for both residents were identified through interviews and record reviews. The Assistant Director of Nursing confirmed the lack of documentation and implementation of care plans, and the Director of Nursing acknowledged that residents should be turned every two hours to prevent pressure injuries. The facility's failure to adhere to care plans and policies resulted in the development and worsening of pressure injuries in both residents.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide rehabilitative services as ordered by the physician for a resident, specifically in the areas of speech therapy and the application of knee splints. The resident, who was admitted with acute respiratory failure, generalized muscle weakness, dysphagia, and gastrostomy status, was dependent on staff for all activities of daily living. The physician had ordered speech therapy three times a week to improve swallow safety and other related functions, but during the week of March 5, 2024, the resident only received therapy twice. This was confirmed by the Director of Rehabilitation Services, who acknowledged the resident should have been seen three times that week. Additionally, the facility failed to document the application of bilateral knee splints for the resident from March 15 to March 31, 2024, as ordered by the physician. The Director of Nursing confirmed there was no documented evidence that the splints were applied during this period, stating that if it was not charted, it was not done. The facility's policies and procedures for speech therapy and restorative nursing assistant services were reviewed, indicating the necessity of following physician orders and providing appropriate treatment to maintain the resident's highest level of functioning.
Inaccurate Documentation of Pressure Injury
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident's pressure injury. The resident, who was admitted with multiple diagnoses including acute respiratory failure, generalized muscle weakness, hyperglycemia, and acute kidney failure, was found to have discrepancies in the documentation of a pressure injury on the left lateral malleolus. The Minimum Data Set (MDS) assessment indicated that the resident's skin was intact with no pressure injuries, while subsequent reports on the same day described the pressure injury differently. The Preliminary Wound Report and Weekly Pressure Injury record both indicated the injury was unstageable, whereas the Wound Consultant Progress Notes described it as a Stage III pressure injury. During an interview, the Director of Nursing acknowledged the error in the wound consultant's progress notes and stated that the facility had contacted the company to issue an amended note. The facility's policy and procedure on documentation principles emphasize the need for clinical records to be accurate, timely, and detailed, consistent with good medical and professional practice. However, the inconsistency in the documentation of the resident's pressure injury indicates a failure to adhere to these standards, resulting in an inaccurate depiction of the resident's status.
Failure to Report Resident Altercations
Penalty
Summary
The facility failed to report a verbal and physical altercation between two residents to the Administrator and the California Department of Public Health (CDPH). On September 13, 2024, a Certified Nursing Assistant witnessed the two residents throwing oatmeal at each other, and on September 14, 2024, a Restorative Nursing Assistant (RNA 1) witnessed a verbal altercation between the same residents. RNA 1 reported the verbal altercation to the Administrator, who did not report it to CDPH, considering it a case of roommate incompatibility rather than mistreatment. The incident on September 13 was not reported to the Administrator at all. Resident 2, who was involved in the altercations, had a diagnosis of anxiety disorder and was capable of making independent decisions. Resident 6, the other resident involved, had a diagnosis of cerebral infarction but was also capable of making decisions and expressing needs. The facility's policy required that any alleged mistreatment or resident-to-resident altercation be reported to the Ombudsman and CDPH, which was not followed in this case. This failure resulted in CDPH being unable to investigate the incidents in a timely manner, potentially leading to the loss of critical information.
Infection Control Lapses in Hemodialysis Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by a Hemodialysis Nurse (HDN 1) and a Hemodialysis Technician (HDT 1) while providing care to two residents undergoing hemodialysis. Both residents were on enhanced barrier precautions due to testing positive for Candida Auris, a yeast that causes severe infections. The HDN and HDT did not cleanse their hands using an alcohol-based hand rub or soap and water, nor did they don the appropriate personal protective equipment, such as gowns and gloves, before providing direct care to the residents. During observations, HDT 1 was seen wearing a disposable gown with the front open, exposing his clothing, and his uniform came into contact with a resident's bed linens. HDN 1 entered the room without cleaning her hands or donning a gown and gloves, and proceeded to touch the residents' beds and medical equipment with bare arms and an uncovered uniform. Both staff members acknowledged their failure to adhere to the facility's infection control procedures, which are crucial to preventing the spread of infections. Interviews with the Infection Preventionist Nurse and the Director of Nursing Services highlighted the importance of all staff, including contracted hemodialysis staff, following the facility's infection control policies. The facility's policies on hand hygiene and enhanced standard precautions require staff to perform hand hygiene before and after direct resident care and to wear gowns and gloves during high-contact tasks to prevent contamination. The non-compliance observed in this case had the potential to inadvertently spread infectious microorganisms to other residents.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to investigate a verbal altercation between two residents that occurred on 9/14/2024. Resident 2, who has an anxiety disorder, and Resident 6, who has a diagnosis of cerebral infarction, were involved in the incident. According to the Minimum Data Set (MDS), both residents were capable of making independent decisions. The altercation began when Resident 2 approached Resident 6 in the dining room, asking to be friends, which led to Resident 6 yelling and moving his hands. Resident 2 responded with racial slurs. This incident was reported to the Administrator by Restorative Nursing Assistant 1 (RNA 1), who also mentioned a previous incident on 9/13/2024 where the residents threw oatmeal at each other. The Administrator did not investigate the incidents, considering the first as a case of roommate incompatibility and claiming unawareness of the second. The facility's policy requires all allegations to be investigated and reported to the California Department of Public Health (CDPH) within five working days. The lack of investigation and reporting constitutes a deficiency, as the facility did not adhere to its policy and procedure for abuse reporting and prevention, potentially allowing for continued conflict between the residents.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after hospitalization, which led to a deficiency. The resident, who had been transferred to a General Acute Care Hospital (GACH) for evaluation due to aggressive behavior, increased agitation, and refusal of care, was cleared by the GACH to return to the facility. Despite this clearance, the facility refused to readmit the resident, resulting in the resident remaining at the GACH for over five months. The facility's refusal was based on the Director of Nursing's (DON 1) assessment that the facility could not meet the resident's psychosocial needs, as the resident was still considered combative and refusing care. The resident had been admitted to the facility with diagnoses including a gastrostomy and schizoaffective disorder, requiring substantial to maximal assistance with activities of daily living. The facility's policy indicated that a Medicaid resident requiring skilled nursing facility services should be readmitted to their previous room if available or to the first available semi-private room. However, despite having available beds, the facility did not comply with this policy. Interviews with facility staff revealed that the decision not to readmit the resident was influenced by concerns about the resident's behavior potentially disturbing other residents.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, affecting all 89 residents. During an observation, a Certified Nursing Assistant (CNA) found black and brown residue inside the ice machine, indicating a lack of proper cleaning. The CNA noted that such residue should not be present if the machine was cleaned daily, as it could lead to mold and bacteria contamination of the ice served to residents. The Maintenance Assistant confirmed that the ice machine was supposed to be cleaned thoroughly once a month, and the presence of residue suggested potential bacterial growth, posing a risk of illness to residents. Additionally, a dented can of applesauce was found among ready-to-use cans in the dry storage area, contrary to the facility's policy of separating damaged cans. The Dietary Supervisor acknowledged that the dented can should have been placed in a designated area for disposal to prevent the risk of botulism, a serious illness caused by improperly sterilized canned foods. The facility's policies on cleaning the ice machine and handling damaged cans were not followed, leading to potential foodborne illness risks for the residents.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist Nurse (IPN) attended and participated in the Quality Assurance and Performance Improvement (QAPI) committee meetings, which are held every 30 days. During a review of the QAPI committee meeting minutes and sign-in sheets for meetings held on 4/8/2024, 5/16/2024, and 6/20/2024, it was found that the IPN did not sign in or present any infection control reports or findings. The Administrator (ADM) confirmed that the IPN's attendance and participation were mandatory to discuss the current infection rate and infection control practices. The ADM and IPN were both new to the facility, and the previous IPN had resigned before a new one was hired. The ADM acknowledged that the facility did not have a policy and procedure for their QAPI Program, which contributed to the oversight. Although the ADM received the infection control summary for May 2024, it was not presented at the QAPI committee meeting. The facility's QAPI Plan, which was undated, indicated that all department heads, including the infection control and prevention officer, should be part of the QAPI Committee. This deficiency in the QAPI process potentially impacted the facility's ability to maintain effective infection control practices.
Infection Control and Food Storage Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Resident 29 had an undated and uninitialed peripheral intravenous catheter (PIV), which made it impossible for nursing staff to determine when it needed to be changed, potentially leading to phlebitis. Resident 57's ventilator tubing was not changed according to the facility's policy, increasing the risk of pneumonia. Additionally, Resident 26's nebulizer mask and tubing were improperly stored and not changed as per the facility's policy, posing a risk of respiratory infection. Resident 192 was placed under incorrect isolation precautions, with Enhanced Barrier Precaution signage instead of the required contact precautions for Carbapenem-resistant Enterobacter. This error could have led to improper use of personal protective equipment (PPE) and increased the risk of spreading the infection. Furthermore, during wound care treatment for Resident 37, improper hand hygiene was observed, which could have contributed to the spread of infection to the resident's wounds. The facility also failed to maintain proper food storage practices. Expired food was found in the resident-designated fridge, and two open bottles of iced coffee were not labeled, posing a risk of foodborne illness. These deficiencies highlight lapses in the facility's infection prevention and control program, as well as in their dietary management practices.
Deficient Fingernail Care for Residents
Penalty
Summary
The facility failed to provide adequate fingernail care for two residents, leading to potential health risks and impacting their quality of care. Resident 15, who was unable to perform activities of daily living due to severe cognitive impairment and physical limitations, was observed with long, jagged fingernails that were digging into the palm of his contracted right hand, causing redness. Despite family members notifying the nursing staff about the issue, the problem persisted, and the family had to trim the nails themselves during visits. The care plan for Resident 15 indicated a need for assistance with personal hygiene, but the facility did not adhere to these requirements. Similarly, Resident 77, who required maximum assistance for personal hygiene due to impaired self-care and functional mobility, was observed multiple times with untrimmed fingernails and a brown substance underneath them. The resident's care plan and assessments highlighted the need for staff assistance with daily living activities, including personal hygiene. However, observations showed that the necessary care was not provided, as the resident's fingernails remained uncleaned and untrimmed over several days. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed that the responsibility for maintaining residents' personal hygiene, including fingernail care, was assigned to CNAs. The facility's policy required fingernails to be cleaned daily and trimmed weekly, but this was not consistently implemented. The failure to provide proper fingernail care for Residents 15 and 77 was a deficiency in the facility's adherence to its policies and procedures, potentially leading to infections and negatively affecting the residents' well-being.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, who was admitted with diagnoses including cerebellar ataxia and parkinsonism, was cognitively intact and required substantial assistance from staff. During observations, the resident was seen trying to reach for the call light, which was on the floor beside the bed, indicating it was not accessible. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that call lights should be within reach of residents to ensure they can request assistance when needed. The facility's policy, dated 1/2017, also stated that call lights should be within easy reach when residents are in bed or seated. Despite this policy, the call light was observed on the floor during multiple observations, highlighting a failure to adhere to the facility's procedures and potentially impacting the resident's quality of life and rights.
Failure to Notify Psychiatrist of Resident's Change in Condition
Penalty
Summary
The facility staff failed to notify the psychiatrist when a resident developed episodes of yelling, which was a change in condition for the resident. The resident, who was admitted with diagnoses including schizophrenia, anxiety, parkinsonism, and hypertension, required maximum assistance for hygiene tasks and lacked the capacity to understand and make decisions. On a specific date, the resident's SBAR communication form indicated increased yelling, and the Primary Care Clinician (PCC) recommended a psychiatrist evaluation. However, there was no documentation that the facility's licensed staff notified the psychiatrist of this change in condition. During interviews, both a Registered Nurse (RN1) and the Director of Nursing (DON) acknowledged the failure to notify the psychiatrist. RN1 stated that the licensed staff should have contacted the psychiatrist after receiving the PCC's order, and the DON emphasized that changes in a resident's condition must be reported to the attending physician immediately. The facility's policy and procedure on changes in condition also required timely assessments and contact with primary care providers, which was not adhered to in this case.
Incomplete MDS Submission for a Resident
Penalty
Summary
The facility failed to transmit the quarterly Minimum Data Set (MDS) to the Centers for Medicare & Medicaid Services (CMS) in a timely manner for one resident, identified as Resident 65. The deficiency was due to incomplete sections D (Mood) and E (Behavior) on the MDS, as well as missing signatures. Resident 65 was initially admitted with multiple diagnoses, including quadriplegia, muscle weakness, osteoarthritis, and neuromuscular dysfunction of the bladder. The resident was dependent on staff for various activities of daily living, such as toileting, bathing, dressing, and personal hygiene. The MDS, dated 4/5/2024, indicated that Resident 65 was able to understand and be understood by others, but the incomplete sections and missing signatures led to the delay in submission. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed that completing the MDS assessment within a week of admission or by the quarterly due date is crucial for optimal care and billing. The MDS Nurse emphasized that all parts of the MDS assessment should be completed by the stated completion date, and any delay could affect the direct care of the resident. The DON reiterated that all sections of the MDS must be completed by the two-week mark after admission or the three-month mark for quarterly submissions, as delays increase the risk of decreased care quality. The facility's policy and procedure on the Minimum Data Set, revised in March 2021, supports timely assessments to ensure proper care management.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop person-centered care plans for three residents, which led to deficiencies in addressing their specific needs. Resident 3, who required maximal assistance with activities of daily living (ADLs) and had unclear speech due to a stroke, did not have a care plan that addressed these issues. Despite being understood by others, Resident 3 had difficulty communicating some words, and the lack of a care plan put her at risk for a decline in communication skills and potential injury if the correct assistance level was not provided. Resident 15, who had severe cognitive impairments and required oxygen therapy, also lacked a care plan for oxygen administration. The resident frequently removed the nasal cannula, which provided supplemental oxygen, yet there were no interventions documented to address this behavior. The absence of a care plan for oxygen therapy meant that staff were not informed of the necessary parameters and interventions, potentially compromising the resident's respiratory care. Resident 65, diagnosed with quadriplegia and dependent on staff for ADLs, did not have a care plan that addressed his total care needs or the increased need for non-pharmacologic interventions. Despite being able to understand and make medical decisions, the resident's care plan did not include specific details about his limitations, which are crucial for staff to provide appropriate care. The lack of comprehensive care plans for these residents indicates a failure to communicate essential care information to the staff, potentially affecting the quality of care provided.
Failure to Ensure Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident remained on continuous oxygen at 3 liters per minute via nasal cannula as ordered by the physician. The resident, who had a history of cerebral infarction, dysphagia, gastroparesis, hyperlipidemia, and hypertension, was observed multiple times with the nasal cannula not in place, which was necessary to maintain adequate oxygen saturation levels. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for assistance with daily activities, including oxygen therapy. Observations revealed that the nasal cannula was often misplaced, either under the resident's chin, in the bed, or on the floor. Interviews with staff, including an LVN and RN, confirmed that the resident frequently removed the nasal cannula, and there was no care plan addressing this behavior. The facility's policy required documentation of any refusal of oxygen and the explanation of risks to the resident, but this was not evident in the records. The Director of Nursing acknowledged the potential for respiratory problems if the resident did not receive oxygen as prescribed.
Failure to Manage Resident's Pain Effectively
Penalty
Summary
The facility failed to effectively manage the pain of a resident, identified as Resident 27, who was admitted with multiple diagnoses including type 2 diabetes, fibromyalgia, and bilateral osteoarthritis of the knee. The resident was cognitively intact and dependent on staff for activities such as toileting, bathing, and personal hygiene. The care plan for Resident 27 specified that pain should be relieved within 30 minutes after medication administration, and staff were instructed to reassess pain levels and notify the physician if additional medication was needed. Despite these instructions, the facility did not adequately assess or manage Resident 27's pain. On multiple occasions, the resident reported experiencing severe pain levels of 7-8 out of 10, even after receiving routine pain medications and non-pharmacologic interventions such as a Lidocaine patch. The Licensed Vocational Nurse (LVN) responsible for the resident admitted to not documenting pain reassessments and failing to offer additional pain medication or notify the physician when the resident's pain was not relieved. Interviews with the resident and staff revealed that the resident continued to experience significant pain that interfered with daily activities. The Director of Nursing acknowledged that pain should be reassessed after medication administration to determine its effectiveness and that unrelieved pain could impact a resident's quality of life. The facility's policy on pain management emphasized the importance of reassessing pain and documenting the effectiveness of interventions, which was not adhered to in this case.
Dialysis Emergency Kit Not Available for Resident
Penalty
Summary
The facility failed to ensure that a dialysis emergency kit was readily available at the bedside for a resident who required dialysis services. This deficiency was identified during observations and interviews with the resident and staff members. The resident, who was admitted with diagnoses including end-stage renal disease and atrial fibrillation, was scheduled to receive hemodialysis three times a week. However, during multiple observations, it was noted that there was no dialysis emergency kit present in the resident's room, either pinned to the wall or inside the nightstand. The resident confirmed that he had not seen a dialysis e-kit in his room. Interviews with the Licensed Vocational Nurse (LVN), Registered Nurse (RN), and the Director of Nursing (DON) revealed that the facility's policy required a dialysis e-kit to be available at the bedside for residents receiving dialysis. The LVN and RN acknowledged that the absence of the e-kit could lead to a delay in intervention if the resident experienced bleeding from the dialysis access site, especially since the resident was on anticoagulant therapy, increasing the risk of bleeding. The DON confirmed that there were no reasons for the e-kit to be missing and emphasized the potential complications of excessive bleeding, such as hypotension and hypovolemic shock.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to properly document the administration of controlled substances for one resident, identified as Resident 27. This deficiency was identified through observation, interview, and record review. Resident 27, who was admitted with diagnoses of fibromyalgia and osteoarthritis, was prescribed Pregablin and Tramadol for pain management. The Medication Administration Record (MAR) indicated that the resident last received Pregablin and Tramadol on a specific date and time. However, upon observation, the blister packs of these medications showed discrepancies in the number of pills remaining, suggesting that the medications were administered but not documented. Licensed Vocational Nurse (LVN) 3 admitted to administering the medications but failing to document the administration in the MAR. This lack of documentation was confirmed during interviews with LVN 3 and the Assistant Director of Nursing (ADON), who both acknowledged the importance of immediate documentation to prevent medication errors and discrepancies. The facility's policy on controlled medications requires that the administration of such drugs be documented immediately, including the date, time, amount administered, and the nurse's signature. The failure to adhere to this policy resulted in an inaccurate medical record for Resident 27, potentially leading to medication errors and issues with drug accountability.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, as evidenced by several deficiencies in medication administration. Licensed Vocational Nurse (LVN) 5 prepared an incorrect dose of Ferrous Sulfate for Resident 50, administering 484 mg instead of the prescribed 330 mg. Additionally, LVN 5 did not check the gastrostomy tube placement or elevate Resident 50's head of bed to the required 35 degrees before administering medication, which is against the facility's policy and procedures. Resident 50, a female with severe cognitive impairment and a diagnosis of gastrostomy status and gastro-esophageal reflux disease, was at risk due to these errors. The facility's policy requires checking the g-tube placement by injecting air and listening for a bubbling sound, which was not done. Furthermore, the head of the bed should have been elevated to prevent aspiration, but it was only raised to 15 degrees. Another deficiency was observed with LVN 6, who failed to disinfect an insulin vial before administering insulin to Resident 75, a male with severe cognitive impairment and a diagnosis of sepsis and type 2 diabetes mellitus. The facility's policy mandates disinfecting medication vials with alcohol to prevent infection, which was not followed. These practices had the potential to result in medication overdose, infection, and aspiration for the residents involved.
Medication Management and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage and label medications and supplies, leading to potential risks in medication administration and diagnostic testing. During an observation, expired medications and supplies, including 69 packets of Banatrol Plus and four bottles of ultrasound gel, were found in the medication storage room. Additionally, Artificial Tears eye drops and Procure Miconazole Nitrate 2% were discovered on a medication cart without proper labeling, lacking resident names and instructions. Interviews with staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed that these items should have been discarded or labeled correctly to prevent potential misuse or cross-contamination. The report highlights the case of a resident who was prescribed Artificial Tears for eye dryness, yet the medication was not labeled with the resident's name, posing a risk of incorrect administration. The facility's policies and procedures for medication storage and administration were not adhered to, as expired items were not removed, and medications were not labeled as required. The Assistant Director of Nursing acknowledged that the RN Supervisor and LVNs were responsible for checking for expired medications and ensuring proper labeling, but these protocols were not followed, resulting in the deficiencies observed.
Failure to Notify Physician of Resident's Aspiration and Vomiting
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner (NP) when a resident aspirated and vomited during feeding. The resident, who had severe cognitive impairment and was dependent on mechanical ventilation, experienced an episode of aspiration and vomiting during a bolus feeding. Despite this significant change in condition, there was no documentation indicating that the resident's physician or NP was informed immediately after the incident. The delay in notification resulted in a delay in treatment and transfer to a General Acute Care Hospital (GACH) for further evaluation. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) notified the Registered Nurse Supervisor (RNS) of the incident, but there was no follow-up to ensure the physician or NP was informed. The Director of Nursing (DON) confirmed that licensed nurses are responsible for notifying the physician or NP of any change of condition. The NP stated that if she had been notified of the aspiration and vomiting, she would have recommended an immediate transfer to a GACH. The facility lacked a policy addressing the notification of a physician in the event of a change of condition.
Failure to Obtain Physician Orders and Delay in Hospital Transfer
Penalty
Summary
The facility failed to ensure that the Respiratory Therapist (RT) obtained orders from the physician or nurse practitioner (NP) before changing the ventilator settings for a resident. This resident, who was admitted with acute respiratory failure and ventilator dependence, had severely impaired cognitive skills and required mechanical ventilation, suctioning, and oxygen therapy. The RT altered the ventilator settings without a physician's order, which is against the facility's policy and procedure. Additionally, the Registered Nurse Supervisors (RNS) did not follow the NP's recommendation to transfer the resident to a General Acute Care Hospital (GACH) when the resident's respiratory rate was abnormal and showed no signs of improvement. Despite the NP's orders and the family's requests, the RNS delayed the transfer, believing the resident was stable enough to continue interventions at the facility. This delay in transferring the resident to a GACH for evaluation and treatment was a significant deficiency. The Director of Nursing (DON) acknowledged that the resident should have been transferred to a GACH based on the NP's recommendation and the resident's lack of improvement. The facility's policies clearly state that ventilator changes require a physician's order and that the physician is responsible for deciding whether a resident should be treated at the facility or transferred to a hospital. The failure to adhere to these policies resulted in the resident receiving unprescribed treatment and a delay in necessary medical intervention.
Seizure Precaution Deficiencies Identified in Residents with Epilepsy and Seizure Disorders
Penalty
Summary
The facility failed to ensure residents with diagnoses of seizure, convulsions, or epilepsy, and on anti-seizure medications had appropriate seizure precautions in place, leading to a serious deficiency. Specifically, Resident 1, diagnosed with epilepsy and systemic lupus erythematosus, was not identified as at risk for seizures upon admission and did not have necessary precautions like padded side rails and a low bed position. This failure resulted in Resident 1 falling from the bed during a seizure activity, sustaining a laceration on her head that required hospitalization. The facility also lacked a policy and procedure for managing residents with seizure diagnoses, further contributing to the deficiency. Additionally, Residents 2 and 3, both with seizure disorders, were found without adequate seizure precautions in place. Resident 2, in a persistent vegetative state and completely dependent on staff, did not have necessary safety measures despite being on seizure medication. Resident 3, with severely impaired cognition and also dependent on staff, had unpadded side rails and lacked proper monitoring for seizure activity. The deficiency extended to the lack of floor mats, pillows, and other safety measures that could have prevented falls and injuries during seizure episodes for these residents.
Failure to Implement Seizure Precautions
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to have a policy and procedure in place for managing and caring for residents with diagnoses of seizures, convulsions, and epilepsy. This deficiency was identified during interviews and record reviews, which revealed that the facility did not implement seizure precautions for 24 residents diagnosed with seizures, convulsions, epilepsy, or those on anti-seizure medications. The lack of seizure precautions placed these residents at risk for falls and injuries during seizure activities. Resident 1 was admitted with diagnoses including epilepsy and systemic lupus erythematosus (SLE) and had a fluctuating capacity to understand and make decisions. Resident 2, admitted with unspecified convulsions, was in a persistent vegetative state and completely dependent on staff for activities of daily living (ADLs). Resident 2 had a physician order for Levetiracetam to be administered through a gastrostomy tube for seizure disorder. Resident 3, admitted with other seizures, had severely impaired cognition and was also completely dependent on staff for ADLs. Resident 3 had a physician order for Levetiracetam to be administered through a gastrostomy tube for seizure disorder. Interviews with staff, including an LVN, RNS, and the DON, revealed that seizure precautions should be implemented upon admission for residents identified at risk for seizures. However, the facility did not have a method to identify these residents, such as wristbands, and lacked a policy on seizure management and precautions. The DON acknowledged that the QAPI committee was focused on other priorities, such as falls, pressure wounds, and abuse training, and had not addressed seizure management and prevention. The facility's QAPI plan indicated that the committee should identify and address specific care and quality issues, but seizure management was not prioritized.
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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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