Pasadena Grove Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1470 N Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 055617
- Inspections on file
- 55
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pasadena Grove Health Center during CMS and state inspections, most recent first.
A resident with dementia, schizoaffective disorder, bipolar disorder, and anxiety had care plans identifying frequent verbal aggression, screaming, and accusations toward staff and others, with interventions directing staff to monitor and document behaviors and medication effectiveness. The January MAR instructed staff on all shifts to tally mood swings and aggressive behaviors, yet no episodes were recorded, despite Change of Condition forms, nursing notes, and staff interviews describing repeated aggressive incidents and hospital transfers for behavior. The Physician Discharge Summary also inaccurately listed elopement attempts as the discharge reason, even though assessments and record review showed no elopement attempts and the DON confirmed the discharge was due to aggressive behavior, contrary to the facility’s policy requiring accurate nursing documentation.
Two residents with cognitive impairment were involved in an incident where one reported being harassed and assaulted by another. The allegation was reported to a nurse, but the facility failed to follow its abuse policy by not reporting the incident to the abuse coordinator or initiating an investigation. Key staff, including the DON and Social Services Director, were not informed, and required documentation and notifications were not completed.
Two residents with cognitive impairment were involved in an incident where one physically and verbally assaulted the other. The assaulted resident reported the event to an RN supervisor, but the required notifications to CDPH, Ombudsman, and police were not made within the mandated two-hour window. Staff interviews and record reviews confirmed that the facility did not follow its abuse reporting policy, resulting in a failure to promptly report the alleged abuse.
A resident with a history of hypertension and cerebral infarct became unusually lethargic and had elevated BP readings over two days. Despite observations by staff and family, the physician was not notified within the required timeframe, and the resident's condition worsened, resulting in hospital transfer for intracranial hemorrhage.
A resident with multiple complex diagnoses repeatedly refused critical medications, including anticonvulsant, antipsychotic, and insulin, over several days. Despite care plan requirements, the physician was not notified after three consecutive refusals, and documentation of resident education and noncompliance was lacking. Insulin was also administered without required blood glucose checks, in violation of facility policy. The DON confirmed these lapses, and facility policies for documentation and monitoring were not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with cognitive impairment and significant physical limitations was subjected to an incident where another resident entered her room, touched her leg and gown, and attempted to take her snacks. Staff and nurses were aware of the ongoing behavior of the resident who entered others' rooms, but the issue persisted, resulting in a failure to uphold the affected resident's right to privacy and dignity.
The facility did not follow its policy to report an allegation of physical abuse within the required two-hour timeframe. A cognitively impaired resident, dependent on staff for care, reported being touched inappropriately by another resident. Although the incident was disclosed to staff, it was not reported to the administrator or authorities until nearly four hours later, contrary to facility policy and regulatory requirements.
Three residents in an LTC facility were found with neglected nail hygiene, despite being dependent on staff for ADLs. One resident had dirty, jagged nails, another had skin tears from scratching with untrimmed nails, and a third had fungal-infected nails. Staff failed to maintain nail care as per care plans, and there was no documentation of residents refusing care.
The facility failed to follow proper food storage and labeling practices, resulting in improperly labeled and expired food items in the kitchen. During an observation, several food items were found without proper labeling, including butter, pork sausage links, chopped spinach, raisins, tea bags, food thickener, and chicken gravy mix. The Dietary Services Supervisor confirmed that the facility's policy requires labeling with received and use by dates, and items must be discarded after the use by date to ensure food safety for residents.
The facility failed to provide education, offer, and document the 2024-2025 COVID-19 vaccinations for two residents and the staff. A resident with cognitive impairments and another with dementia did not have up-to-date vaccinations, and there was no record of consent or administration. Additionally, the facility lacked documentation for staff vaccinations, as the Infection Prevention Nurse found no records of staff being offered or receiving the vaccine.
The facility failed to ensure call lights were within reach for two residents, both with moderate cognitive impairments and at risk for falls. One resident's call light was found on the floor, while another's was between the side rails and mattress, making them inaccessible. Staff confirmed the call lights were not within reach, contrary to facility policy, which requires call cords to be accessible for resident communication.
A facility failed to accurately complete the PASRR assessment for a resident with schizophrenia, depression, and dementia. The PASRR Level I Screening incorrectly indicated no serious mental illness, despite the resident's psychiatric diagnoses and medication use. Staff interviews revealed confusion over responsibility for PASRR accuracy, contributing to the deficiency.
A resident with schizophrenia, dementia, and Parkinsonism, assessed at high risk for falls, experienced an unwitnessed fall. The facility failed to update the resident's fall care plan following the incident, despite policies requiring care plan revisions after falls. This oversight was confirmed by the MDS Nurse and DON, highlighting a deviation from established procedures.
A resident with a history of contracture and hemiplegia did not receive prescribed Restorative Nursing Services, including PROM exercises and hand splint application, as ordered by the physician. The care plan was not updated to reflect new orders, and multiple days of services were missed, leading to a deficiency in care. Interviews confirmed the failure to execute the necessary interventions to prevent contractures and maintain mobility.
A resident receiving oxygen therapy at 5 LPM did not have a physician's order, as required by the facility's policy. Despite the resident's intact cognitive skills, multiple observations confirmed the absence of a documented order. Interviews with the DON, MDSN, and an LVN corroborated this deficiency, highlighting a failure to adhere to the facility's oxygen administration policy.
A facility failed to provide adequate dialysis care for a resident with ESRD by not ensuring the prescribed fluid intake of 1800 ml per day and not monitoring the resident's AVF for dialysis access. The resident's fluid intake was consistently below the prescribed amount, and there was no documentation of shunt site monitoring every shift, as required by the care plan and facility policy. This failure had the potential to cause dehydration and delay in detecting complications.
A resident with dementia and other conditions was prescribed chewable Aspirin for stroke prophylaxis. However, the resident swallowed the tablet whole instead of chewing it, as observed by an LVN. The DON confirmed that the medication should have been separated to ensure proper administration. This failure could potentially affect the medication's absorption and effectiveness.
A facility failed to act on a pharmacist's recommendations during a Medication Regimen Review for a resident with quadriplegia, seizures, and encephalopathy. The resident received a higher than recommended dose of Aspirin for CVA prophylaxis, which was not addressed by notifying the physician, as required by facility policy. The oversight led to the resident continuing the higher dose throughout February, despite potential gastrointestinal side effects.
The facility failed to keep the lids of a dumpster closed as per policy, potentially attracting vermin. Observations revealed the dumpster with open lids and an unsecured gate. Interviews with the Maintenance and Dietary Supervisors confirmed the policy requirement to keep lids closed to prevent disease transfer.
A facility failed to provide hospice services for a resident with end-stage cardiovascular accident by not scheduling required visits from hospice nurses and CHHAs as per the care plan. The hospice calendar for February 2025 was incomplete, and there was no documentation of CHHA visits for January and February 2025. Interviews with staff confirmed the lack of scheduled visits and documentation, contrary to the facility's end-of-life care policy.
A resident was inappropriately administered antibiotics despite not meeting the necessary criteria according to the facility's Antibiotic Stewardship protocol. The resident, admitted with sepsis and other conditions, received a full course of Invanz without meeting Loeb's Minimum Criteria. The Infection Prevention Nurse and DON acknowledged the oversight, highlighting a lapse in protocol adherence.
A resident with multiple health conditions did not receive a pneumococcal vaccine despite consenting to it, due to an oversight by the Infection Prevention Nurse who failed to review the resident's medical records. The facility's policy requires documentation of vaccination or reasons for non-vaccination, which was not followed.
The facility failed to post accurate nursing hours, as the information displayed on 2/25/2025 was dated 2/24/2025, leading to non-compliance with the facility's policy. This was confirmed by the IPN and DON, who acknowledged the discrepancy in the posted data.
The facility did not meet the required 80 square feet per resident in 31 rooms, as observed during a survey. Despite the deficiency, residents and staff reported no issues with space, and a waiver request was submitted, indicating the rooms were sufficient for care and privacy. The Department recommended approval of the waiver.
The facility failed to monitor intake and output for two residents with indwelling catheters, as required by its policy. One resident was readmitted with a UTI, CKD, and anemia, while another was admitted with a UTI and urinary retention. Both care plans required intake and output monitoring, which was not performed. The DON stated there was no physician's order for monitoring, but facility policy mandated it for residents with catheters.
Two residents in an LTC facility did not receive appropriate pain management as per physician's orders. One resident with quadriplegia reported severe pain but was given medication for mild pain without notifying the physician. Another resident with cancer received medication for mild pain despite experiencing moderate pain. Facility policies on pain management and physician notification were not followed.
A resident's rights were violated when his cellphone was confiscated by staff without his consent, despite being self-responsible. The phone was removed based on a request from a family member without legal authority, and staff failed to document the action or inform the resident. The facility's policy requires residents to be informed and their consent documented when personal possessions are taken.
A resident with quadriplegia and chronic kidney disease, who was being monitored for hematuria, did not have a urine sample collected for urinalysis as ordered by the physician. Despite the physician's order, the nursing staff failed to follow through, and no laboratory requisition form was completed or sent. The facility's policy on coordinating laboratory services was not adhered to, resulting in a deficiency in providing timely laboratory services.
A facility failed to provide a communication board for a resident with limited English proficiency, despite the resident's need for such an aid due to language barriers. The resident, with diagnoses including diabetes, schizophrenia, and dysphagia, required assistance with daily activities and had moderate cognitive impairment. Interviews and observations confirmed the absence of the communication board, contrary to the facility's policy to support residents with language barriers.
A facility failed to create and implement a care plan for a resident with inappropriate behavior and wandering tendencies. Despite reports of inappropriate comments and observed wandering, the MDS Nurse did not develop a care plan, and the Elopement Risk Assessment was not updated to reflect the resident's high risk. The facility's policy required care plans to be updated with changes in the resident's condition, which was not done.
A resident with a history of inappropriate behavior and wandering was inadequately supervised, resulting in them entering another resident's room and an allegation of inappropriate touching. Despite the resident's need for supervision, the facility failed to update their care plan and elopement risk assessment, contrary to their policies.
A resident with quadriplegia and intact cognitive skills was unable to use the standard call light due to paralysis. The call light was tied to the bed rail and out of reach, and the resident resorted to calling 911 for help. The facility's policy required adaptive call lights based on residents' needs, which was not provided.
The facility failed to ensure call lights were within reach and answered promptly for two residents, leading to potential delays in care. One resident, with multiple health issues, often found his call light out of reach and experienced delayed responses, especially at night. Another resident, with multiple sclerosis, had to use her phone to call for assistance due to an inaccessible call light. Staff interviews confirmed the facility's policy of keeping call lights within reach and responding within five minutes, but these measures were not consistently followed.
The facility failed to provide appropriate care for three residents, including not assessing or documenting a pacemaker dressing change for one resident and not checking or changing diapers every two hours for two others. Staffing shortages contributed to these deficiencies, impacting the ability to meet residents' needs. The facility's policies on documentation and resident care were not followed, leading to potential risks of infection and skin breakdown.
A resident with moderate cognitive impairment and a history of falls experienced unrelieved severe pain due to the facility's failure to administer prescribed pain medications. Despite recorded pain levels indicating severe pain, neither Acetaminophen nor Tramadol was administered as per physician orders. Additionally, the resident's call light was not answered promptly, further delaying pain relief. The facility's policies on pain management and call system communication were not adhered to, resulting in this deficiency.
Two residents in a LTC facility did not receive their prescribed medications as ordered, resulting in a deficiency. The MARs for both residents showed blank entries for multiple medications, indicating they were not documented as administered. Interviews with staff revealed that the medications might not have been given, contrary to the facility's policy requiring documentation of medication administration.
A CNA in an LTC facility failed to demonstrate competency in managing a resident at high risk for falls, despite attending relevant in-service training. The resident, with a history of dementia and repeated falls, required frequent monitoring and specific interventions, which the CNA was unaware of. Interviews with facility staff highlighted the expectation for CNAs to be knowledgeable about residents' fall risk status and necessary interventions, as outlined in the facility's Falling Star Program.
The facility failed to monitor the WanderGuard system for two residents, both with impaired cognitive skills and at risk of elopement. Despite physician orders and care plans requiring daily checks, there was no documentation of monitoring from March to May 2024. The facility also lacked a system to test the functionality of the WanderGuard bracelets once applied, contrary to its policy and the user guide.
The facility failed to follow its abuse policy by not timely investigating and reporting an abuse allegation involving two residents with cognitive impairments. Despite documentation of the incident, the facility did not report it to the CDPH or submit a follow-up investigation report due to a communication lapse between the ADM and DON.
Inaccurate Behavior Monitoring and Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation for a resident with multiple psychiatric diagnoses, including dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and anxiety disorder. The resident’s care plans, initiated and updated in December and January, identified verbal aggression, racial and derogatory remarks, screaming at others, and accusations that staff were hurting or stealing from her. Interventions included administering medications as ordered and monitoring and documenting behaviors, including the time and day of occurrences, as well as monitoring for side effects and effectiveness of psychotropic medications. Despite these documented behavior problems and care plan directives, the resident’s January MAR instructed staff on all three shifts to monitor episodes of mood swings manifested by aggressive behavior toward others and to tally them with hashmarks every shift, yet the MAR showed no mood swing or aggressive behavior episodes from early January through late January. This lack of documentation conflicted with multiple staff interviews and other records. The DON and CNA reported that the resident was verbally aggressive toward staff and residents, screamed at CNAs and nurses, especially during medication administration, and exhibited aggressive behavior about three times a week, sometimes daily since December. Change of Condition forms and nursing notes showed transfers to the hospital due to aggressive behavior in December and January, further contradicting the absence of behavior tallies on the MAR. Additionally, the Physician Discharge Summary inaccurately documented the reason for the resident’s discharge as attempts to elope, even though the Elopement Risk Assessment rated the resident as low risk for elopement and a review of Change of Condition reports and nursing notes from late January to early February revealed no elopement attempts. The DON confirmed that the true reason for discharge was the resident’s aggressive behavior, not elopement, and acknowledged that the discharge summary was inaccurate. The facility’s own nursing documentation policy required concise, clear, pertinent, and accurate documentation, which was not met in the behavior monitoring on the MAR or in the stated reason for discharge on the Physician Discharge Summary.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure for two residents when it did not investigate an allegation of abuse. On 12/18/2025, one resident reported to a registered nurse that she was being harassed and assaulted by another resident. The reporting resident described an incident where the other resident went through her clothes, punched her in the chest, called her derogatory names, and made offensive remarks. The resident stated she reported this incident to the nurse, but there was no evidence that the allegation was reported to the abuse coordinator or that an investigation was initiated as required by facility policy. Both residents involved had moderately impaired cognitive skills for daily decision making and required varying levels of assistance with activities of daily living. The resident who reported the abuse had diagnoses including type 2 diabetes mellitus, hypertension, and schizoaffective disorder, while the other resident had diagnoses including malignant neoplasm of the vulva, chronic diastolic heart failure, and cardiomegaly. Despite the report of abuse, the staff member who received the allegation did not follow the facility's policy to report and investigate the incident, and key personnel such as the Social Services Director and Director of Nursing were not informed in a timely manner. Interviews with staff confirmed that the facility's abuse prevention and reporting policy was not followed. The Social Services Director and Director of Nursing both stated they were unaware of the abuse allegation until after the fact, and the registered nurse admitted she did not report the incident as required. The facility's policy mandates prompt investigation and reporting of abuse allegations to appropriate authorities, but this process was not initiated, and documentation was lacking.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged abuse incident involving two residents to the required authorities within the mandated two-hour timeframe after the allegation was reported to a Registered Nurse Supervisor (RNS). According to interviews and record reviews, one resident, who had moderately impaired cognitive skills and required assistance with daily activities, reported being physically assaulted and verbally abused by another resident. The assaulted resident informed the RNS about the incident, but the RNS did not report the allegation to the California Department of Public Health (CDPH), Ombudsman, or local law enforcement as required by facility policy and state regulations. Staff interviews confirmed that all facility staff are mandated reporters and are aware that suspected abuse or allegations of abuse must be reported to the appropriate state agencies immediately or within two hours of becoming aware of the incident. Despite this, the RNS did not follow the facility's abuse policy, and the Director of Nursing (DON) was not informed of the abuse allegation or the reason for the police visit to the facility. The Social Services Director (SSD) also was not notified about the incident or the involvement of law enforcement until after the fact. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The failure to report the abuse allegation in a timely manner was confirmed through staff interviews and documentation review, demonstrating noncompliance with both facility policy and regulatory requirements.
Failure to Timely Notify Physician of Change in Condition and Elevated Blood Pressure
Penalty
Summary
The facility failed to immediately notify the physician of a resident's change in condition, specifically for a resident with a history of hypertension and cerebral infarct. On two consecutive days, the resident was observed by staff and family to be sleepier than usual, which was a deviation from their normal behavior. Despite these observations being reported to licensed nursing staff, there was no timely notification to the physician regarding the resident's altered mental status. On the morning of the second day, the resident's blood pressure was recorded at 153/91 mmHg, which was elevated compared to normal values. The facility's policy required that such changes in condition be reported to the physician within 15 minutes. However, the physician was not notified of the elevated blood pressure at that time. Progress notes indicated that the physician was only made aware of the resident's refusal of medication, not the elevated blood pressure or the change in mental status. Later that day, the resident's condition deteriorated further, with blood pressure rising to 210/92 mmHg and the resident becoming lethargic and unresponsive. The resident was subsequently transferred to a hospital, where a CT scan revealed a significant intracranial hemorrhage. Interviews with staff and review of records confirmed that the physician was not notified in a timely manner about the resident's change in condition, contrary to facility policy and the care plan instructions.
Failure to Notify Physician and Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that medications were administered to meet the needs of a resident and in accordance with professional standards of practice. Specifically, a resident with multiple diagnoses, including depression, schizoaffective disorder, psychosis, anxiety disorder, insomnia, and type 2 diabetes mellitus, experienced multiple episodes of medication refusal involving anticonvulsant, antipsychotic, and insulin medications. Despite care plan interventions requiring physician notification after three consecutive refusals, the physician was not notified of these repeated refusals. The care plan also required monitoring and documentation of noncompliance, as well as education for the resident and family, but these actions were not consistently documented or performed. The resident's Medication Administration Record (MAR) showed numerous refused doses of critical medications over several days, including anticonvulsant, antipsychotic, antidepressant, and insulin. Additionally, insulin was administered on several occasions without obtaining the required blood glucose checks beforehand, contrary to the facility's policy and procedure for medication administration. The Director of Nursing (DON) confirmed that the physician was not notified of the refusals and that licensed nurses did not document education provided to the resident regarding medication refusals. The DON also acknowledged that the Interdisciplinary Team (IDT) did not address the resident's refusal of blood glucose checks and medication refusals as required by policy. A review of the facility's policies indicated that documentation of medication refusals should include the date and time, the medication refused, the resident's reason for refusal, the name of the person attempting administration, information provided to the resident about the consequences of refusal, the resident's condition, and notification of the attending physician. The policies also required that vital signs or testing, such as blood glucose monitoring, be completed and recorded prior to medication administration. These procedures were not followed, resulting in deficient practice related to medication administration and documentation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Failure to Maintain Resident Privacy and Dignity Due to Inadequate Monitoring
Penalty
Summary
A resident with multiple medical conditions, including type 2 diabetes, end stage renal disease, and hypertension, was admitted to the facility and assessed as having moderately impaired cognitive skills and requiring significant assistance with daily activities such as toileting and bathing. The resident reported that another male resident entered her room without permission, touched her leg and gown, and attempted to take her snacks. Staff interviews and documentation confirmed that the male resident had a pattern of entering other residents' rooms, taking their belongings, and required frequent redirection by staff. The affected resident expressed discomfort and fear during the incident, stating she was unable to get up and feared retaliation if she resisted. Staff, including CNAs and nurses, were aware of the male resident's behavior, as he was known to enter other residents' rooms and take their items. Despite this knowledge, the male resident continued to access other residents' rooms, including the incident where he touched the affected resident and attempted to take her snacks. Facility policies reviewed indicated a requirement to promote privacy, dignity, and respect for residents, but these were not upheld in this instance, resulting in a failure to maintain the resident's right to privacy and dignity.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to ensure that an allegation of physical abuse was reported to the California Department of Public Health (CDPH), local law enforcement, and the Ombudsman within two hours, as required. The incident involved a resident with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, and hypertension, who was cognitively impaired and dependent on staff for daily activities. This resident reported that another male resident entered her room and touched her leg and gown, which made her feel uncomfortable and fearful. The event was initially reported by a Certified Nurse Assistant (CNA) to the charge nurse around 7:30 PM, and the resident's responsible party later called the facility to report the same allegation. Despite the facility's policy requiring immediate reporting of abuse allegations, the Licensed Vocational Nurse (LVN) did not report the incident at the time it was disclosed, citing being occupied with medication administration. The LVN also did not instruct another nurse to report the allegation to the administrator. The administrator was eventually informed of the incident around 9:30 PM, and the abuse allegation was officially reported at 11:11 PM, nearly four hours after the initial disclosure. The Director of Nursing (DON) confirmed that the reporting should have occurred within two hours of the resident's claim, and the delay was acknowledged during interviews and record reviews. The second resident involved, who also had cognitive impairment and mental health diagnoses, was identified as the individual who entered the female resident's room. Staff interventions included 1:1 monitoring and notification of the physician, but the primary deficiency was the failure to report the abuse allegation within the required timeframe. The facility's policy, reviewed with the DON, clearly stated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the appropriate authorities.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services for three residents who were dependent on staff for activities of daily living (ADLs). Resident 28, who was admitted with diagnoses including dysphagia, depression, and diabetes mellitus, was observed with dirty, long, and jagged fingernails. Despite the care plan indicating the need for nails to be kept clean and trimmed, observations and interviews revealed that Resident 28's nails were not maintained, potentially leading to skin injury and infection. There was no documentation of the resident refusing nail care, and staff acknowledged the importance of maintaining proper hygiene to prevent health issues. Resident 27, admitted with conditions such as dysphagia, diabetes mellitus, and hemiplegia, also exhibited signs of neglect in nail care. Observations showed Resident 27 scratching themselves with dirty and jagged nails, resulting in skin tears and blood smears. The care plan required nails to be kept clean and trimmed, but interviews with staff confirmed that the resident's nails were not properly maintained, increasing the risk of self-harm and infection. No documentation was found indicating that Resident 27 refused nail care. Resident 38, with diagnoses including encephalopathy and dementia, was found with long, discolored, and potentially fungal-infected nails. The care plan specified that nails should be kept clean and trimmed, yet observations showed significant neglect in nail care. Interviews with staff revealed that the condition of Resident 38's nails was not reported to the charge nurse or physician, despite the visible signs of fungal infection and detachment from the nail bed. The facility's policy required referral to a podiatrist for such conditions, but this was not done, leaving the resident at risk of infection.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its food storage handling practices as outlined in its policy and procedure, which led to the presence of improperly labeled and expired food items in the kitchen's refrigerators, freezers, and dry storage. During an observation and interview with the Dietary Aide and Kitchen Aide, several food items were found without proper labeling, including an opened cube of butter, a carton of pork sausage links, a bag of chopped spinach, and multiple boxes of raisins and tea bags. Additionally, cans of food thickener and a bag of chicken gravy mix were not labeled with use by dates, contrary to the facility's policy. The Dietary Services Supervisor (DSS) confirmed that the facility's policy requires all food items to be labeled with a received date and a use by date once opened, and that items must be discarded after the use by date to ensure food safety for residents. The facility's Policy and Procedure on Food Storage and Handling, which was revised recently, mandates labeling and dating of all food items and storage products, with specific guidelines for storing opened products in containers with tight-fitting lids. The failure to follow these procedures had the potential to result in foodborne illness among the 50 residents consuming food at the facility.
Failure to Document and Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to adhere to its COVID-19 vaccination policy by not providing education, offering, and documenting the 2024-2025 COVID-19 vaccinations for two residents and the staff. Resident 2, who was admitted with diagnoses including schizophrenia, dementia, and Parkinsonism, had a moderately impaired cognitive ability and required substantial assistance for daily activities. The Minimum Data Set (MDS) indicated that Resident 2's COVID-19 vaccination was not up to date, and there was no record of consent, refusal, or administration of the vaccine. The Infection Prevention Nurse (IPN) confirmed that consent was not obtained, and the resident had not received the vaccination. Similarly, Resident 17, diagnosed with dementia, depression, and hypothyroidism, also had moderately impaired cognitive skills and was dependent on assistance for various activities. The MDS for Resident 17 showed that their COVID-19 vaccination was not up to date, and there was no documentation of consent, refusal, or administration of the vaccine. The IPN acknowledged the absence of a consent or declination form and confirmed that Resident 17 had not received the vaccine. Additionally, the facility did not maintain records for staff vaccinations, as there was no documentation indicating which employees were offered, received, or declined the 2024-2025 COVID-19 vaccine. The IPN, who took over the responsibility for employee immunizations after the departure of the Director of Staff Development, found no documentation for the staff's COVID-19 vaccinations. The facility's policy required education and offering of the vaccine to staff and residents, with proper documentation, but these steps were not followed, placing residents and staff at risk of COVID-19 infection.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 17 and 28, had their call lights within reach, which is a necessary accommodation for their needs. Resident 17, who has diagnoses including dementia, depression, and hypothyroidism, was observed with a call light on the floor, out of reach. This resident, who is dependent on assistance for various activities and at moderate risk for falls, was unable to locate the call light to request help. A Certified Nursing Assistant confirmed the call light was not supposed to be on the floor and should have been within the resident's reach. The Director of Nursing acknowledged that call lights are essential for residents to contact staff in emergencies and for assistance. Similarly, Resident 28, who has conditions such as dysphagia, depression, and diabetes, was found with a call light positioned between the side rails and mattress, making it inaccessible. This resident, who requires substantial assistance for daily activities and is at moderate risk for falls, was unaware of the call light's location and resorted to yelling for assistance. A Licensed Vocational Nurse confirmed the call light was out of reach and emphasized its importance for resident communication. The facility's policy mandates that call cords be placed within residents' reach, highlighting the deficiency in adhering to this policy.
Inaccurate PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accurate completion of the Preadmission Screening and Resident Review (PASRR) assessment for a resident with a mental illness. The resident, who was initially admitted and later readmitted to the facility, had diagnoses of schizophrenia, depression, and dementia with behavioral disturbance. Despite these diagnoses, the PASRR Level I Screening indicated that the resident did not have a serious mental illness or related condition, which was inaccurate. This discrepancy was identified during a review of the resident's records, which showed the resident was on antipsychotic and antidepressant medications and had a history of psychiatric disorders. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for ensuring the accuracy of the PASRR assessments. The Director of Nursing indicated that the Registered Nurse Supervisor was responsible for the PASRR's accuracy, while the Registered Nurse Supervisor believed the MDS Nurse was responsible. However, the MDS Nurse stated that the Admissions Coordinator was responsible for the PASRR. This lack of clarity and accountability contributed to the inaccurate completion of the PASRR, potentially affecting the resident's access to necessary psychiatric treatment and evaluation.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to update and revise the fall care plan for a resident, identified as Resident 2, following an unwitnessed fall. Resident 2, who was initially admitted with diagnoses including schizophrenia, dementia with behavioral disturbance, Parkinsonism, and difficulty in walking, was assessed to be at high risk for falls. Despite this, the resident's fall care plan, last revised in July 2024, was not updated after a fall incident on October 6, 2024. The Minimum Data Set (MDS) indicated that Resident 2 required substantial assistance for various movements, and the fall risk assessments showed an increase in fall risk from moderate to high. However, the care plan did not reflect these changes or the fall incident, which was acknowledged by the MDS Nurse and the Director of Nursing (DON) during interviews. The facility's policy and procedure for fall management and care planning require that care plans be revised following a fall to implement new interventions and ensure resident safety. Despite these guidelines, the care plan for Resident 2 was not updated after the fall, which was confirmed by both the MDS Nurse and the DON. The failure to revise the care plan after the fall incident was a deviation from the facility's established policies, potentially placing Resident 2 at risk for further falls.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, leading to a deficiency in care. The resident, who had a history of right hand contracture, hemiplegia, hemiparesis, and chronic respiratory failure, was not receiving the prescribed passive range of motion (PROM) exercises and hand splint application consistently. The physician's orders included PROM exercises for the right upper extremity and bilateral lower extremities, as well as the application of a Carrot hand splint, but these were not carried out as required. The resident's care plan, which was supposed to be updated with new orders for restorative nursing services, was not revised to include the bilateral lower extremity exercises. The Restorative Nursing charting showed multiple instances where the resident did not receive the ordered services, with several days missing for both the hand splint application and PROM exercises. Observations confirmed that the resident's right hand was closed in a fist, indicating a lack of proper intervention. Interviews with the Restorative Nursing Assistant (RNA) and the Director of Nursing (DON) revealed that the RNA services were not being performed as ordered, and the care plan was not updated accordingly. The RNA acknowledged that the services were necessary to prevent contractures and maintain mobility, but they were not executed as prescribed. The DON emphasized the importance of following physician orders to monitor and improve the resident's condition, which was not happening in this case.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had a physician's order for the treatment. Resident 16, who was admitted with diagnoses including dysphagia, pneumonia, and pleural effusion, was observed multiple times with oxygen administered via nasal cannula at 5 liters per minute (LPM). Despite the resident's cognitive skills being intact, there was no documented physician's order for the oxygen therapy in the resident's medical records. Interviews with the Director of Nursing (DON), the Minimum Data Set Nurse (MDSN), and a licensed vocational nurse (LVN 1) confirmed the absence of a physician's order for the oxygen therapy. The facility's policy and procedure for oxygen administration, which requires a physician's order specifying the flow rate, method of administration, and other details, was not followed. This oversight had the potential to negatively impact the resident's breathing pattern, as the proper dosage and route of administration were not verified by a physician's order.
Failure to Provide Adequate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease (ESRD) by not ensuring the resident received the prescribed 1800 milliliters of fluids per day. The resident's care plan and physician orders specified a fluid restriction of 1800 ml per day, with detailed allocations for dietary and nursing shifts. However, a review of the Medication Administration Record (MAR) for February showed that the resident's daily fluid intake ranged from 240 ml to 960 ml, with only two days reaching closer to the prescribed amount. This significant underloading of fluids had the potential to cause dehydration, as noted by the registered nurse during the interview. Additionally, the facility did not adequately monitor the resident's arteriovenous fistula (AVF) for dialysis access, as required by the facility's policy and the resident's care plan. The care plan indicated that the resident was at risk for infection at the shunt site and required monitoring for symptoms of infection, as well as physical inspection for redness, swelling, or pain. However, the medical records for February did not show evidence of staff monitoring the shunt site every shift, as confirmed by the registered nurse during the interview. The Director of Nursing (DON) acknowledged the importance of monitoring intake and output to prevent dehydration or fluid overload and emphasized the need for staff to check the fistula for proper functioning and signs of infection. The facility's policy on dialysis care required staff to inspect the shunt site for various symptoms once per shift, but this was not documented in the resident's records. The lack of adherence to these protocols resulted in a failure to provide the necessary care for the resident's dialysis needs.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a medication was administered per the physician's order for one of the residents, identified as Resident 21. The resident, who had a history of dementia with agitation, metabolic encephalopathy, and hypertension, was prescribed a chewable Aspirin tablet of 81 mg to be taken once daily for stroke prophylaxis. However, during an observation, it was noted that the resident swallowed the Aspirin tablet whole instead of chewing it, as required for proper absorption. This was confirmed by the Licensed Vocational Nurse (LVN 2) who administered the medication, acknowledging that the resident drank all her medications at once, including the chewable Aspirin. The Director of Nursing (DON) later stated that the Aspirin should have been separated from the other medications to ensure it was chewed. The facility's policy on medication administration, revised in 2017, indicated that medications should be administered by a licensed nurse according to the physician's order. The failure to administer the Aspirin as prescribed had the potential to delay absorption and decrease the effectiveness of the medication, which could affect the resident's wellbeing.
Failure to Act on Pharmacist's Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act upon the Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR) for a resident in January 2025. The resident, who had diagnoses including quadriplegia, seizures, and encephalopathy, was receiving Aspirin 325 mg daily for CVA prophylaxis, which was higher than the recommended dose of 81 to 162 mg. The consulting pharmacist noted this irregularity and recommended clarification with the medical doctor due to potential gastrointestinal side effects from the higher dose. However, the facility did not notify the physician or follow up on the pharmacist's recommendation, resulting in the resident continuing to receive the higher dose throughout February 2025. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nurses, revealed that the monthly MRR was not reviewed or acted upon as required by the facility's policy. The Director of Nurses acknowledged that the Quality Assurance team and nursing staff should have reviewed the MRR to prevent potential medication misuse or overdose. The facility's policy mandates that any irregularities reported by the pharmacist must be reviewed and acted upon by the attending physician, with documentation of the physician's response within 30 days, which did not occur in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the lids of a garbage container (dumpster) remained closed as required by the facility's policy on garbage and trash can use and cleaning. During observations on two separate occasions, the dumpster was found with one or both lids open, and the gate to the dumpster area was not closed. This was contrary to the facility's policy, which mandates that dumpster lids be kept closed at all times to prevent the attraction and spread of vermin. Interviews with the Maintenance Supervisor and Dietary Supervisor confirmed that the facility policy required the dumpster lids to be closed to keep out flies and rodents and prevent disease transfer. A review of the facility's policy further indicated that food waste should be placed in covered garbage and trash cans.
Failure to Ensure Hospice Services for Resident
Penalty
Summary
The facility failed to ensure the provision of hospice services for a resident by not adhering to the hospice care summary order. The resident, who was under hospice care due to a terminal prognosis of end-stage cardiovascular accident, required visits from hospice nurses and certified home health aides (CHHA) as per the care plan. However, the hospice calendar for February 2025 was incomplete, lacking scheduled visits from skilled nurses (SN) and CHHAs, which were necessary for the resident's comfort and symptom management. The record review revealed that the hospice plan of care summary orders required CHHA services twice a week and SN visits once a week. Despite this, the hospice monthly calendar showed missing scheduled visits for both SNs and CHHAs throughout February 2025. Additionally, there was no documentation in the hospice flow sheet for January and February 2025 indicating that CHHAs visited the resident, highlighting a lack of coordination and documentation of hospice services. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed the absence of scheduled visits and documentation. The hospice performance improvement coordinator also acknowledged that hospice staff should sign in using the hospice binder when visiting residents. The facility's policy on end-of-life care emphasized the need for care plans to reflect hospice interventions as ordered, which was not adhered to in this case.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol, resulting in the inappropriate administration of antibiotics to a resident. Resident 206, who was admitted with diagnoses including sepsis, urinary tract infection, and extended spectrum beta lactamase resistance, was administered Invanz, an antibiotic, for six days. However, the resident did not meet the Loeb's Minimum Criteria for initiating antibiotics, which include a temperature greater than 100°F or 2.4°F above baseline, and at least one additional symptom such as rigors or delirium. Despite this, the resident received the full course of antibiotics without the necessary criteria being met. The Infection Prevention Nurse acknowledged that the resident did not meet the criteria for antibiotic use and that the physician should have been notified. The Director of Nursing stated that a time out for antibiotic use should have been conducted after three days to reassess the necessity of the antibiotic. The facility's policy on Antibiotic Stewardship emphasizes the importance of monitoring antibiotic use to prevent resistance and adverse events, but this protocol was not followed in the case of Resident 206.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer a pneumococcal vaccination to a resident, despite obtaining consent for the vaccine. The resident, who was admitted with diagnoses including end-stage renal disease, type 2 diabetes mellitus, and a history of myocardial infarction, was identified as being at higher risk for complications from pneumococcal disease due to their immunocompromised status. The resident's medical records indicated that the pneumococcal vaccine was ordered and consent was obtained on February 7, 2025, but the vaccine was not administered. The Infection Prevention Nurse acknowledged the oversight, stating that they did not review the resident's medical records for vaccinations and failed to administer the vaccine. The Director of Nursing confirmed that all residents are offered and educated about immunizations, and that consented immunizations should be administered. The facility's policy on pneumococcal disease prevention requires documentation of vaccination or reasons for non-vaccination, but this was not adhered to in this case.
Inaccurate Posting of Nursing Hours
Penalty
Summary
The facility failed to post accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD) information as required by their policy and procedure. On 2/25/2025, the posted nursing hours for direct care staff were observed to be inaccurate as they were dated 2/24/2025 instead of the current date. This discrepancy was confirmed during an interview with the Infection Preventionist Nurse (IPN), who acknowledged that the posted information was not accurate for the day in question. Further review of the facility's Policy and Procedure (P&P) with the Director of Nursing (DON) revealed that the facility's policy required the posting of the current date and the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. The policy also mandated that this information be posted daily at the beginning of each shift in a clear and readable format accessible to residents and visitors. The DON confirmed that the facility did not comply with these requirements, as the posted information on 2/25/2025 was outdated, thus making it inaccurate.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 31 of 31 resident rooms met the required minimum of 80 square feet per resident in multiple resident rooms. This deficiency was identified during an initial tour observation, interviews, and record reviews. The rooms in question were found to be below the required square footage, with some rooms providing as little as 69.3 square feet per resident. Despite the deficiency, interviews with residents and staff indicated that there were no complaints regarding the room sizes, and staff were able to perform their tasks without space concerns. The facility's Client Accommodation Analysis Form and room waiver request confirmed the deficiency, listing specific rooms and their measurements, which fell short of the regulatory requirements. The waiver request indicated that the rooms, although smaller than required, were deemed sufficient for nursing care, comfort, and privacy of the residents. The Department recommended approval of the room waiver request for all 31 rooms, acknowledging the facility's efforts to address the space limitations.
Failure to Monitor Intake and Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to monitor the intake and output for two residents with indwelling catheters, as required by the facility's policy. Resident 1, who was readmitted with diagnoses including a urinary tract infection, chronic kidney disease, and anemia, was noted to have an indwelling catheter. The care plan for Resident 1 indicated the need to monitor and document intake and output, but this was not done. Similarly, Resident 3, admitted with a urinary tract infection and urinary retention, also had an indwelling catheter. The care plan for Resident 3 required monitoring and documentation of intake and output, which was not performed. During a review of the facility's policies, it was found that intake and output recording is mandatory for residents with indwelling catheters. The Director of Nursing stated that the facility did not have documentation for the intake and output of these residents because there was no physician's order for such monitoring. However, the facility's policy clearly required intake and output monitoring for residents with indwelling catheters, regardless of a physician's order. This oversight had the potential to delay necessary care and services for the residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents as per the physician's orders and facility policy. Resident 1, who was admitted with diagnoses including quadriplegia, depression, and anxiety, reported a pain level of 7/10. Despite this, the Licensed Vocational Nurse (LVN) administered acetaminophen 650 mg, which was only indicated for mild pain levels of 1-3, without notifying the physician of the increased pain level. The Registered Nurse Supervisor confirmed that the physician was not informed, and non-pharmacological interventions were not provided while waiting for further pain management orders. Resident 2, diagnosed with malignant neoplasm of the right breast, depression, and anxiety, experienced a pain level of 4 on two occasions. However, the Director of Nursing (DON) noted that acetaminophen 500 mg was administered, which was only indicated for mild pain levels of 1-3, contrary to the physician's order. The facility's policy required notifying the physician of any new onset or change in pain, which was not adhered to in these cases. The facility's policies on pain management, medication administration, and change of condition notification were not followed, leading to the inappropriate administration of pain medication and failure to notify the physician of changes in the residents' pain levels. This oversight had the potential to result in unnecessary and preventable pain for the residents, as the facility staff did not adhere to the established protocols for managing and reporting pain.
Resident's Rights Violation: Cellphone Confiscation
Penalty
Summary
The facility failed to honor the rights of a resident by not allowing him to keep his personal cellphone at his bedside, as per his request. The resident, who was admitted with diagnoses including quadriplegia, depression, and anxiety, was identified as a self-responsible party. Despite this, the facility staff removed his cellphone shortly after admission, allegedly to prevent him from making calls to emergency services, without his consent or proper documentation. The resident's cellphone was found in a medication cart, and staff members were aware of its location but did not return it to him. Interviews with staff revealed that the removal of the cellphone was based on a request from a family member who did not have legal authority to make decisions for the resident. The facility's policy requires that residents be informed and their consent documented when their personal possessions are taken, which was not followed in this case. The Director of Nursing acknowledged that the resident's rights were violated, as he was self-responsible and should have been allowed to retain his cellphone. The facility's policy emphasizes the importance of treating residents with respect and dignity, allowing them to exercise their rights without interference. The lack of documentation and failure to follow the resident's wishes were identified as key issues leading to this deficiency.
Failure to Obtain Urine Sample for Urinalysis
Penalty
Summary
The facility failed to obtain a urine sample for urinalysis as ordered by the physician for a resident with quadriplegia, urinary tract infection, and chronic kidney disease. The resident was admitted with an indwelling catheter and was being monitored for hematuria. Despite the physician's order for a urinalysis with culture and sensitivity on the day hematuria was noted, the sample was not collected or sent to the laboratory. Interviews with the nursing staff revealed a lack of follow-through on the physician's order. The Licensed Vocational Nurse acknowledged not obtaining the urine sample and was unsure if the Treatment Nurse had done so. The Minimum Data Set Registered Nurse confirmed that no laboratory results were available because the urine sample was not sent out, and there was no documentation of a laboratory requisition form being completed or the laboratory being contacted for specimen collection. The Director of Nursing emphasized the importance of executing physician orders to determine the presence of a urinary tract infection and the type of bacteria involved. However, a review of the facility's policy indicated that laboratory services should be coordinated and documented, which was not adhered to in this case. The failure to collect and process the urine sample as ordered resulted in a deficiency in providing timely laboratory services to meet the resident's needs.
Failure to Provide Communication Board for Resident with Language Barrier
Penalty
Summary
The facility failed to provide a communication board for one resident, who was identified as having a language barrier, which was necessary for effective communication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus with chronic kidney disease, schizophrenia, and dysphagia, was noted to have moderate cognitive impairment and required assistance with daily activities. Despite the resident's limited English proficiency and the facility's policy to aid residents with language barriers through communication boards, no such board was available in the resident's room. Interviews with the resident and staff confirmed the absence of a communication board, which was supposed to facilitate communication between the resident and the staff. The facility's policy emphasized the importance of providing communication aids to ensure residents with limited English proficiency have equal access to services. However, observations revealed that the communication board was neither present in the resident's current room nor in the previous room, indicating a lapse in adhering to the facility's policy and procedures.
Failure to Develop Individualized Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized resident-centered care plan for a resident who exhibited inappropriate behavior and wandering tendencies. Despite receiving a report from the transferring facility about the resident's inappropriate comments to female staff, the MDS Nurse did not observe such behavior during admission and therefore did not develop a care plan addressing it. Additionally, the resident was noted to be wandering on a specific date, but a care plan for wandering was not developed, which was contrary to the facility's policy. The resident's Elopement Risk Assessment initially indicated a low risk for wandering, but after episodes of wandering were observed, the assessment should have been updated to reflect a high risk. The Director of Nursing acknowledged that the resident should have been monitored and supervised according to policy due to the high risk of wandering. The facility's policy required care plans to be updated with changes in the resident's condition or needs, but this was not done, leading to a deficiency in care planning for the resident.
Inadequate Supervision Leads to Resident Wandering and Allegation
Penalty
Summary
The facility failed to provide adequate supervision for a resident who exhibited inappropriate behavior and episodes of wandering. This deficiency was observed when the resident wandered into another resident's room, leading to an allegation of inappropriate touching. The resident, who was admitted with diagnoses including adult failure to thrive, COPD, and hypertension, was noted to have intact cognitive skills for daily decision-making but required supervision for various activities. Despite a report from a transferring facility indicating the resident's inappropriate behavior, no care plan was developed upon admission as the behavior was not observed initially. The facility's policy required monitoring for behavioral triggers such as wandering, but the resident's Elopement Risk Assessment was not updated to reflect the increased risk after wandering episodes were observed. The Director of Nursing acknowledged that the resident should have been monitored and supervised according to policy. The facility's policy on safety and elopement risk reduction emphasized the need for monitoring and supervision to ensure resident safety, which was not adequately implemented in this case.
Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a call light was within reach and did not provide an adaptive call light for a resident with quadriplegia, anxiety disorder, and generalized muscle weakness. The resident was dependent on others for daily activities and had intact cognitive skills for decision-making. The care plan indicated the use of a phone to call the facility for help instead of a call light. However, during an observation, the call light was found tied to the bed rail and not within the resident's reach. The resident expressed the inability to use the call light due to paralysis and the need for an adaptive device that could be activated by blowing air. The Director of Nursing acknowledged the issue and attempted to place the call light within reach, but the resident confirmed the inability to use it due to nerve damage. The resident resorted to calling 911 for help as they did not have the nurse station's number. A Certified Nursing Assistant confirmed that the resident called for help by yelling, which was not always effective. The facility's policy required call lights to be within reach and adaptive devices to be provided based on residents' needs, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were within reach and not answering them promptly. Resident 1, who was admitted with multiple health issues including a complete atrioventricular block, right-sided hemiplegia, and moderate cognitive impairment, reported that his call light was often out of reach, leading him to rely on his roommate's call light for assistance. He expressed frustration over the delayed response times, particularly during the night shift, which exceeded the facility's policy of answering within five minutes. Resident 4, diagnosed with multiple sclerosis and chronic pain syndrome, also experienced issues with her call light being out of reach. On one occasion, she had to use her cell phone to call the nurses' station for assistance with a diaper change, as her call light was not accessible. Observations confirmed that her call light was placed at the head of her bed, out of her reach, and she had to request staff assistance to reposition it. Interviews with facility staff, including a CNA, a Registered Nurse Supervisor, and the Director of Staff Development, confirmed that the facility's policy required call lights to be within residents' reach and answered within three to five minutes. The staff acknowledged the importance of adhering to this policy to prevent potential accidents or emergencies. However, the facility's failure to consistently implement these measures resulted in the deficiency noted in the report.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for three residents according to professional standards and its own policies. For Resident 1, the facility did not assess, document, or notify the attending physician about the status of the resident's pacemaker dressing. The resident, who had a history of complete atrioventricular block and a pacemaker, accidentally removed the dressing and called paramedics out of concern. Despite the paramedics' involvement, there was no documentation of the incident or notification to the attending physician, as confirmed by interviews with the nursing staff and a review of the resident's records. For Residents 4 and 6, the facility failed to check and change their diapers every two hours or as needed, leading to potential risks of skin breakdown. Both residents had moderate cognitive impairment and required substantial assistance with toileting. Resident 4 reported not having her diaper changed for 12 hours on two occasions, and Resident 6 experienced delays in receiving assistance after using the call light. Interviews with CNAs revealed that staffing shortages contributed to these deficiencies, with CNAs being assigned more residents than they could adequately care for, resulting in unmet needs for timely diaper changes and repositioning. The facility's policies on documentation, change of condition notification, and resident care were not followed, as evidenced by the lack of documentation and communication regarding the incidents. The facility was also short-staffed, which impacted the ability to provide necessary care and services, as confirmed by the Director of Staff Development and the Administrator. These deficiencies had the potential to lead to infections and skin breakdowns for the affected residents.
Failure in Pain Management and Call Light Response
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 2, by not adhering to its own policy and procedure on pain management. Resident 2, who was admitted with diagnoses of repeated falls and anxiety, was noted to have moderate cognitive impairment and required varying levels of assistance with daily activities. The resident's Minimum Data Set indicated occasional moderate pain, and active physician orders included Acetaminophen for mild pain and Tramadol for moderate to severe pain. However, the Medication Administration Record for July showed no administration of either medication on days when the resident's pain level was recorded as 7, indicating severe pain. Observations and interviews revealed that Resident 2's call light was not answered promptly, and the resident expressed upset due to not receiving pain medication. The Director of Nursing acknowledged that the call light should have been answered within five minutes and that the resident should have received timely pain medication. The facility's policies on call system communication, resident rights, and pain management emphasize prompt response and timely interventions, which were not followed in this case, leading to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer prescribed medications to two residents, resulting in a deficiency. Resident 2, who was admitted with multiple diagnoses including COPD, hypothyroidism, depression, anxiety, and schizophrenia, did not receive several medications as ordered on a specific date. The medications included Aspirin, Buspirone, Colace, Cymbalta, Depakote, Flonase, MiraLAX, Pro-Stat, Seroquel, Synthroid, and Ensure supplement. The Medication Administration Record (MAR) for Resident 2 showed blank entries for these medications, indicating they were not documented as administered. Similarly, Resident 3, who was readmitted with diagnoses such as seizures, chronic kidney disease, bipolar disorder, and COPD, also did not receive their prescribed medications on the same date. The medications included Amlodipine, Carbamazepine, Depakote, Eliquis, Gabapentin, Levetiracetam, Olanzapine, Pro-Stat, Prozac, and Risperidone. The MAR for Resident 3 also had blank entries for these medications, suggesting they were not administered as required. Interviews with the Registered Nurse Supervisor and the nurse assigned to the residents on the date in question revealed that the medications were not documented as given, and the nurse admitted it was possible the medications were not administered. The facility's policy requires medications to be administered according to physician orders and documented in the MAR, which was not followed in these cases.
Deficiency in Fall Risk Management
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) had the necessary competency to care for a resident at high risk for falls. The resident, who had a history of dementia, repeated falls, and other medical conditions, was assessed as a moderate fall risk and had a care plan indicating high fall risk. The care plan required frequent monitoring and specific interventions to prevent falls. However, CNA 1, who was assigned to monitor the resident, was unaware of the resident's fall risk status, history of falls, and the necessary interventions to prevent further falls. Interviews with facility staff revealed that CNA 1 did not know why the resident required a sitter and was not aware of the resident's fall history or the interventions needed. The Registered Nurse (RN) and Director of Nursing (DON) stated that CNAs should be knowledgeable about the residents they are assigned to, including their history, fall risk status, and required interventions. The DON emphasized the importance of the Falling Star Program, which uses visual cues like stars on doors and wristbands to identify residents' fall risk levels, and stated that staff should be able to apply the knowledge from in-service training to their daily work. Despite attending in-service training on fall prevention and the Falling Star Program, CNA 1 did not demonstrate the expected competency in identifying and managing residents at risk for falls. The facility's policy and procedures, including the Fall Management Program, were not effectively implemented by CNA 1, leading to a deficiency in ensuring resident safety and care as per the established guidelines.
Failure to Monitor WanderGuard System
Penalty
Summary
The facility failed to ensure proper monitoring and functionality of the WanderGuard system for two residents, which is crucial for preventing elopement. Resident 1, who was readmitted with multiple diagnoses including schizophrenia and major depressive disorder, was identified as having impaired cognitive skills and required assistance with daily activities. Despite having a physician's order and care plan indicating the need for monitoring the WanderGuard every shift, there was no documented evidence of such monitoring from March to May 2024. The Director of Nursing confirmed the lack of documentation for monitoring the WanderGuard's placement and function. Similarly, Resident 2, admitted with conditions such as schizophrenia and bipolar disorder, also had impaired cognitive skills and required assistance with daily activities. The resident's care plan and physician's order also required monitoring of the WanderGuard every shift. However, there was no documentation of this monitoring in the Medication Administration Records for the same period. The Registered Nurse Supervisor acknowledged that the staff only tested the WanderGuard before application, not daily as required. Additionally, the facility lacked a system to test the functionality of the WanderGuard bracelets once applied to residents. The Administrator was unaware of any process to check the function of the bracelets, although maintenance staff checked the door systems. The facility's policy required daily checks of the WanderGuard system, but this was not being followed, as confirmed by the review of the facility's policy and the WanderGuard user guide.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating and reporting an allegation of abuse in a timely manner for two residents. Resident 1, who has moderate cognitive impairment and various mental health diagnoses, alleged abuse involving Resident 2, who also has moderate cognitive impairment and mental health issues. The incident involved Resident 2 banging on the adjoining bathroom door and yelling at Resident 1, leading to a verbal altercation. Despite the incident being documented as a change of condition, the facility did not report the allegation to the California Department of Public Health (CDPH) or submit a follow-up investigation report. During interviews, the Licensed Vocational Nurse (LVN) and the facility's Administrator (ADM) and Director of Nursing (DON) acknowledged the incident and the failure to report it. The facility's policy requires that a completed investigation report be provided to the Administrator within five working days and that the Administrator report the results to the appropriate agencies. However, due to a communication lapse between the ADM and DON, the required reports were not filed, and no investigation notes were available for review by surveyors.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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