Pelican Ridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport Beach, California.
- Location
- 466 Flagship Road, Newport Beach, California 92663
- CMS Provider Number
- 055121
- Inspections on file
- 43
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 64
Citation history
Health deficiencies cited at Pelican Ridge Post Acute during CMS and state inspections, most recent first.
A resident on contact isolation for C. diff had active orders for contact precautions and hemodialysis access site monitoring, including dressing changes to a central catheter in the right upper chest. Surveyors observed an RN performing a dressing change in the resident’s room, which was posted with a contact precaution sign and had an isolation cart, while not wearing a gown as required for contact precautions. The RN confirmed awareness of the resident’s contact isolation status and acknowledged that a gown should have been worn, and the DON later confirmed that staff are expected to wear gown and gloves in contact isolation rooms in accordance with infection control practices.
A resident with orders for carvedilol for HTN and midodrine for hypotension had medications inconsistently administered in relation to ordered BP and HR parameters. Review of MARs showed multiple instances where carvedilol was held despite BP/HR not meeting hold criteria or with no vitals documented, and midodrine was both held when BP did not meet the ordered threshold and administered when SBP exceeded the prescribed limit. The DON verified these discrepancies, and the Administrator confirmed that facility policy requires licensed nurses to follow physician orders.
A resident with severe cognitive impairment was started on IV fluid therapy without documentation that her family member was informed of the treatment, its risks, benefits, or alternative options. Nursing staff confirmed the lack of notification and documentation regarding the therapy, and the family member only learned of the IV fluids during a visit.
A resident with severe cognitive impairment was physically abused by another resident with a known history of aggression, resulting in injury. Staff and witness interviews confirmed the incident, but the injured resident was not monitored for 72 hours as required by policy. The aggressive resident had prior episodes of aggression, and documentation of required follow-up, including care conferences and social services consultation, was incomplete.
A resident with severe cognitive impairment and CHF did not have daily weights documented as ordered by the physician, nor was there evidence of refusal. After sustaining a head injury with swelling, the resident's follow-up monitoring and care were not documented, despite facility policy requiring such actions after a change in condition.
A resident with severe cognitive impairment received IV fluids as ordered, but the facility did not develop or implement a care plan to address the use of IV therapy. This omission was confirmed through medical record review and staff interviews, indicating the resident's needs related to IV therapy were not formally addressed.
A resident with terminal CVA and severe cognitive impairment did not have required hospice visits properly documented, as the hospice binder lacked evidence of recent skilled nurse and aide visits. Facility nursing staff did not routinely check or record hospice visits, and hospice staff sometimes failed to sign the binder, leading to a lack of confirmation that ordered hospice care was provided.
A resident with decision-making capacity repeatedly refused ADL care, dialysis, medications, and wound assessments, leading to a surgical wound with sutures going unassessed and untreated for several months. The facility did not develop a care plan to address these refusals, and staff confirmed that the lack of such a plan contributed to missed care and delayed wound management.
A resident's care plan was not updated or reassessed after experiencing two falls, one of which resulted in new skin tears. Despite facility policy and regulatory requirements, the care plan did not reflect the resident's current status or evaluate the effectiveness of interventions. Nursing staff and the DON confirmed the care plan should have been revised following these incidents.
A resident was admitted with a surgical incision and sutures, but the facility did not develop a baseline care plan to address wound care needs as required. The omission was confirmed through medical record review and interviews with the DON and Administrator, resulting in the resident's wound care needs not being met for an extended period.
A resident was admitted with a surgical incision and sutures, but staff failed to assess, monitor, or provide wound care for several months until an outpatient dialysis clinic alerted the facility. The wound and sutures were not addressed in the care plan or progress notes, despite being visible and the resident requiring maximum assistance with ADLs. The DON confirmed that required skin assessments and protocols were not followed.
A resident experienced two falls, but staff did not complete required post-fall assessments, neurological checks, or 72-hour monitoring, and failed to notify the physician and the resident's representative. Facility policy for post-fall care and documentation was not followed, as confirmed by staff interviews and medical record review.
Surveyors found that two residents requiring CPAP therapy did not receive proper respiratory care: one resident's CPAP mask was stored unsanitarily on the floor without a storage bag, and another resident did not have a CPAP machine provided as ordered. Facility staff and leadership confirmed these deficiencies.
Two residents did not receive dialysis care as ordered: one did not attend scheduled hemodialysis sessions at an outpatient center due to unarranged transportation, and another had incorrect documentation of their dialysis access device, with staff and records specifying the wrong type of vascular access. These failures resulted in care not being provided according to physician orders.
The facility did not ensure that nursing staff demonstrated required competencies in skin assessment, resulting in a surgical wound not being assessed or cared for over an extended period. Additionally, a resident did not receive prescribed lidocaine patches for pain management, as staff failed to follow physician orders and facility medication administration policies.
A resident with orders for lidocaine patches for pain management did not receive the prescribed patches on two consecutive days, despite documentation on the MAR indicating administration. The DON confirmed the patches were not applied and remained in the medication cart, and pharmacy records supported that no additional patches were delivered. This resulted in a failure to administer and accurately document pain medication as ordered.
Two residents experienced incomplete and inaccurate documentation in their medical records, including missing and incorrect entries in behavior monitoring and medication administration records. These failures were confirmed by the DON and nursing staff, and contradicted both facility policy and physician orders.
A resident with multiple complex medical conditions was discharged without documented instructions or education regarding necessary care, including Foley catheter and nephrostomy care. Facility records, including the Post Discharge Plan of Care and Skilled Evaluation Notes, lacked required entries, and staff confirmed that documentation of discharge education was missing.
Two residents with a history of verbal aggression and roommate dissatisfaction were not separated despite repeated complaints and staff awareness, leading to one resident pushing a table that struck the other in the head and caused injury. Staff failed to act on requests for a room change and did not intervene when threats were made, resulting in physical harm.
The facility did not thoroughly investigate an abuse allegation between two residents by failing to interview a roommate who was present during the incident, despite facility policy requiring interviews with all individuals who may have relevant information. The omission was confirmed by both the SSD and Administrator, and the roommate later provided details about the altercation when interviewed by surveyors.
Two residents experienced significant unaddressed weight loss due to the facility's failure to implement timely monitoring, IDT assessment, and required notifications. Despite care plans and physician orders for supplements and weight checks, the facility did not consistently monitor weights, update care plans, or initiate a Change of Condition, resulting in missed interventions for nutrition and hydration.
A facility failed to ensure accurate medical records for a resident's enteral feeding. The resident was ordered Jevity 1.5, but the MAR showed [NAME] Farms 1.4, which the facility did not have. Staff administered Jevity 1.5 but documented it incorrectly, failing to clarify and update the MAR. The DON confirmed these findings.
Two residents with indwelling urinary catheters experienced deficiencies in care at the facility. One resident's catheter drainage bag was observed on the floor, contrary to CDC guidelines, and lacked a care plan for UTI treatment. Another resident experienced frequent catheter leakage, but the physician was not notified, and the catheter size was not clarified. These issues highlight failures in catheter maintenance and communication with physicians.
A resident's POLST indicating a DNR order was not followed when they were found unresponsive, leading to the initiation of CPR. The POLST was not immediately accessible, and CPR was continued at a family member's request, despite the resident's documented wishes. The facility's policy required advance directives to be easily accessible, which was not adhered to.
The facility failed to maintain the nutritive content and palatability of pureed food, as pureed vegetables were held in a hot oven for over an hour, potentially reducing essential nutrients. Additionally, a test tray inspection revealed that the breadstick served was crusty and hard to chew, which was verified by the Kitchen Supervisor and RD Consultant.
The facility failed to ensure food safety and sanitation in the kitchen, as observed during a survey. Opened food items in the freezer were not labeled or dated, leading to freezer burn, and food preparation equipment was not properly air-dried before storage. Additionally, a cutting board was heavily marred, making it difficult to clean and sanitize. The Kitchen Supervisor acknowledged these issues.
The facility failed to conduct regular inspections and entrapment assessments for bed safety, affecting several residents using side rails or halo grab bars. The Maintenance Director did not perform routine checks or assess all necessary zones for entrapment risks, as required by policy. Residents with cognitive impairments and mobility issues were at risk due to these oversights.
The facility's call light system was found to be deficient in multiple rooms, with issues such as non-functioning lights and lack of audible alerts at nursing stations. These deficiencies were confirmed through observations and staff interviews, highlighting a failure to adhere to the facility's policy for reporting and documenting defective call lights.
A resident did not receive necessary medical care due to the facility's failure to coordinate and document appointments with an infectious disease physician and an oncologist. The appointments were either marked as completed without evidence or discontinued without scheduling, as confirmed by staff interviews.
A facility failed to renew informed consent for a resident prescribed Seroquel, as required by the Nursing Facility Resident Informed Consent Protection Act of 2023. The resident, unable to make decisions, had no updated consent for the medication, which was confirmed by an LVN and the DON during a survey.
The facility failed to ensure call lights were within reach for two residents, potentially delaying their ability to request assistance. One resident, capable of using the call light, was found with it clipped to the wall, while another had it under a pillow after a therapy session. Both residents expressed needs that could not be promptly addressed due to the inaccessibility of the call lights.
The facility failed to develop comprehensive care plans for four residents, neglecting to address specific medical needs such as pressure injuries, fluid restrictions, ear treatments, and isolation precautions. These omissions were confirmed through medical record reviews and interviews with facility staff, highlighting deficiencies in individualized care planning.
The facility failed to provide adequate pressure ulcer care for two residents. One resident's wound care did not follow infection prevention protocols, leading to contact with a soiled diaper. Another resident's heels were not properly offloaded as per physician's orders, and their care plan lacked necessary interventions. Staff confirmed these deficiencies, and the DON acknowledged the findings.
A facility failed to document necessary PICC line measurements for a resident, as required by physician's orders and facility policy. The medical record lacked documentation of the external catheter length and arm circumference upon admission, which was confirmed by both a nurse and the DON. This oversight could delay identifying catheter-related complications.
The facility failed to provide adequate respiratory care for three residents, with issues including improper storage of equipment and lack of documentation in the MAR. A resident's Yankauer suction was not stored correctly, and oxygen saturation levels were not recorded for two residents, despite physician orders. Another resident's nasal cannula tubing was found on the floor, and their oxygen therapy was not documented. Staff confirmed these deficiencies, and the DON acknowledged the lack of proper documentation.
A facility failed to document the administration of controlled medications for a resident, as required by its policy. The Narcotic and Controlled Substances Count Sheet lacked the necessary nurse's signature for morphine sulfate and lorazepam, which were administered to the resident. The DON confirmed the findings and acknowledged the deficiency, which could lead to medication diversion.
A facility failed to monitor a resident's use of psychotropic medications, including Seroquel and sertraline, by not completing monthly behavior summaries and not documenting behavior manifestations and side effects. Staff interviews confirmed the lack of required documentation, indicating non-compliance with the facility's policy.
A facility's medication error rate was found to be 16%, exceeding the acceptable limit of 5%. An LVN failed to check a resident's heart rate before administering metoprolol and did not follow physician orders for administering Colace, metformin, and ferrous sulfate. The DON acknowledged these errors and emphasized the importance of adhering to physician orders.
A resident was administered metoprolol without checking their heart rate, contrary to physician's orders requiring the medication to be held if the heart rate was below 60 bpm. The LVN confirmed the oversight, and the DON acknowledged the need for adherence to medication administration parameters.
The facility failed to properly label and store medications, including unlabeled multi-dose vials, improper storage of discharged residents' medications, and incorrect separation of external and oral medications. These deficiencies were confirmed by LVNs and acknowledged by the DON, highlighting lapses in adherence to medication management protocols.
A facility failed to follow its policy on the safe handling and storage of food items brought in by family or visitors for a resident. Opened food items, including jam, pickles, Gatorade, and butter, were found at a resident's bedside without refrigeration, contrary to the facility's policy. Staff confirmed the oversight, and the resident, who was capable of making decisions, stated they would ask staff to refrigerate items as needed.
The facility failed to document routine checks in its Water Management Program and did not maintain a clean environment in the laundry room. Additionally, infection control practices were not followed for two residents: one lacked a physician's order for contact isolation, and another did not have Enhanced Barrier Precautions implemented as ordered. Staff failed to adhere to proper protocols, including hand hygiene and wearing protective equipment.
The facility failed to maintain essential equipment safely, with glucometers showing out-of-range control results without corrective actions and a medication refrigerator with ice buildup and stains. The DON acknowledged these issues, indicating a lack of adherence to protocols for equipment maintenance and quality control.
The facility failed to honor and document advance directives for three residents, leading to potential discrepancies in care. A resident's advance directive conflicted with their POLST, another resident's advance directive was not obtained, and a third resident was not provided information on formulating an advance directive. Staff interviews confirmed these deficiencies.
Two residents in a facility were not provided with their scheduled showers due to isolation precautions, despite being able to make medical decisions and express their preferences. Resident 48 received only two showers since admission, and Resident 374 received only one shower, both scheduled for twice-weekly showers. The facility staff confirmed that residents on droplet precautions were only given bed baths, not showers, despite the possibility of adhering to isolation protocols to allow for showers.
The facility failed to maintain proper nutritional and hydration status for two residents. One resident did not receive the recommended nutritional drinks, impacting their caloric and protein intake, while another resident's fluid intake was not monitored despite a physician-ordered fluid restriction. These deficiencies were due to a lack of adherence to dietary recommendations and inadequate monitoring by the facility staff.
The facility failed to store trash in a sanitary manner, with three out of four dumpsters found uncovered, potentially harboring pests. This was observed outside the kitchen by the parking structure, and the Administrator was informed and seen addressing the issue.
The facility did not submit complete and accurate direct care staffing information to CMS, leading to a trigger for extremely low staffing on weekends from January to March 2024. The Administrator acknowledged not submitting the complete hours worked by staff, risking inaccurate auditable data reporting.
A facility failed to update a resident's care plan to reflect a change in antibiotic medication and the need for contact isolation precautions. The resident was prescribed Levaquin for a UTI, but the care plan still listed Cipro and did not include contact isolation for ESBL in urine. Staff confirmed the oversight, and the DON acknowledged the findings.
A resident with DM, DVT, and May-Thurner Syndrome did not receive aspirin and apixaban as ordered by the physician. The DON and Administrator confirmed the discrepancies, acknowledging that the medications were either not entered or incorrectly entered in the MAR, leading to the resident not receiving the necessary care.
Failure to Use Required PPE for Resident on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and CDC guidance for contact precautions for a resident on isolation for Clostridioides difficile (C. diff). The facility’s policy titled “Infection Surveillance” (revised 12/2022) stated that infection surveillance is a core activity of the infection prevention and control program, intended to identify infections and monitor adherence to infection prevention practices to reduce and prevent the spread of infections. CDC guidance for Transmission-Based Contact Precautions (dated 4/2024) requires the use of appropriate PPE, including wearing a gown and gloves for all interactions that may involve contact with the resident or the resident’s environment when the resident has an infection that poses increased risk for contact transmission. Resident 3 was admitted on an unspecified date and had physician orders dated 2/18/26 for contact precautions related to C. diff and for hemodialysis access site monitoring for a central catheter in the right upper chest, with dressing changes at the dialysis center and as needed every shift, and monitoring for signs and symptoms of infection. The resident’s H&P dated 2/25/26 documented that the resident had capacity to make medical decisions. On 3/12/26 at 1617, surveyors observed a contact precaution sign and isolation cart outside the resident’s room, while RN 1 was inside the room kneeling at the bedside performing a dressing change on the resident’s dialysis site without wearing a gown. In a subsequent interview, RN 1 confirmed the resident was on contact isolation for C. diff, acknowledged she was not wearing a gown, and stated she should have worn one, noting that contact precautions include donning a gown and gloves. The DON later verified the resident was on contact isolation for C. diff and stated she expected staff to wear gowns and gloves in contact isolation rooms and that proper PPE use ensures infection control is maintained. The Administrator and DON acknowledged the findings during interview.
Failure to Follow Physician Parameters for Antihypertensive and Vasopressor Medications
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services in accordance with physician orders for one resident who had capacity and was readmitted to the facility in late November. The facility’s policy on medication administration required that medications be given according to written physician orders. The resident had orders for carvedilol 3.125 mg twice daily for hypertension, to be held only if systolic blood pressure (SBP) was less than 100 mmHg or heart rate was less than 60, and for midodrine (initially 2.5 mg, later increased to 5 mg) twice daily for hypotension, to be held if SBP exceeded specified thresholds (greater than 130 mmHg, later greater than 140 mmHg). Review of the MARs for December and January showed multiple instances where these parameters were not followed. In December, carvedilol was held on several occasions when documented BP and heart rate did not meet the ordered hold parameters, and in multiple instances the drug was held with no vital signs documented at all. Midodrine was held once when the BP was 127/71, which did not meet the ordered hold parameter, and was administered on several occasions when the recorded SBP exceeded the ordered threshold (e.g., SBP 145 and 152). Similar issues continued into January, with carvedilol held when vital signs did not meet hold criteria and with missing heart rate documentation, and midodrine both held without any documented vital signs and administered when SBP was above the ordered limit. During interviews, the DON verified these findings, and the Administrator acknowledged that facility policy required licensed nurses to follow physician orders.
Failure to Inform Resident and Family of IV Therapy and Alternatives
Penalty
Summary
The facility failed to ensure that a resident and her family member were fully informed about the initiation of intravenous (IV) fluid therapy, including the risks, benefits, and alternative treatment options. The resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was started on Dextrose Intravenous Solution 5% per physician orders. Medical record review showed no documentation that the family member was notified about the IV therapy, its potential effects, or provided with alternative options prior to administration. During interviews, the family member confirmed that she was not informed about the IV fluids and only became aware of the therapy upon visiting the resident. Nursing staff verified that the IV fluids were administered and acknowledged the lack of documentation regarding the indication for the therapy and the absence of family notification. The Director of Nursing was made aware of these findings and acknowledged the deficiency.
Failure to Protect Resident from Physical Abuse and Inadequate Post-Incident Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was severely cognitively impaired, was sitting in the activities room when another resident, who had a documented history of aggression, hit the first resident on the right hand, resulting in visible redness. Witnesses, including another resident and an activities assistant, confirmed the incident, and a licensed vocational nurse assessed the injury. However, the medical record did not show evidence that the injured resident was monitored for 72 hours post-incident, as required by facility policy. The resident who committed the abuse had a care plan indicating the use of psychotropic medication for bipolar disorder with a history of verbal and physical aggression. Previous documentation showed this resident had been involved in another physical altercation with a different resident and had multiple episodes of aggression toward staff. Despite these incidents, the medical record lacked documentation of a change in condition, progress notes, or notification to the family and physician for the earlier aggressive episode. Interviews with staff, including CNAs, LVNs, and the DON, confirmed that the resident with a history of aggression was not consistently monitored or documented according to policy after incidents. Additionally, a recommended social services consultation for the aggressive resident was not documented as completed. The facility's failure to follow its own policies for monitoring, documentation, and intervention after abuse incidents contributed to the deficiency.
Failure to Document and Provide Ordered Care Following Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident with severe cognitive impairment who had a physician's order for daily weights for three days due to CHF. Medical record review showed there was no documentation that daily weights were obtained or that the resident refused to be weighed, as required by the physician's order. Interviews with nursing staff confirmed the absence of documentation regarding the daily weights or any refusals by the resident. Additionally, after the resident sustained a bump on the head resulting in a lump with swelling, the facility did not document monitoring, care, or safety measures provided following the incident. Although the resident was observed with the injury and the physician ordered a hospital evaluation, the resident remained in the facility after paramedics determined transfer was not necessary. There was no evidence in the medical record of follow-up monitoring or documentation of the resident's condition after the injury, despite facility policy requiring such documentation for changes in condition or extraordinary events.
Failure to Develop Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the use of intravenous (IV) fluids for one resident. Medical record review showed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was admitted and subsequently received orders for Dextrose Intravenous Solution 5% and Dextrose Intravenous Solution 5% with multivitamin. The IV fluids were administered as ordered, with documentation confirming administration on specific dates. Despite the administration of IV therapy, there was no evidence in the resident's medical record that a care plan was developed to address this intervention. This was verified during interviews with both an RN and the DON, who acknowledged the absence of a care plan for the resident's IV therapy. The lack of a documented care plan meant that the resident's individual needs related to IV therapy were not formally identified or addressed in the care planning process.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination and documentation of hospice services for one resident with a terminal diagnosis of cerebrovascular disease and severe cognitive impairment. The resident had physician orders for hospice care, including skilled nurse visits once a week and hospice aide visits twice a week. However, review of the hospice binder and sign-in sheets revealed that the last documented hospice aide visit was nearly two months prior, and the last skilled nurse visit was several weeks prior to the review. There was no evidence in the hospice binder to confirm that the required visits were being completed as ordered. Interviews with facility nursing staff, including an RN and an LVN, revealed that they did not routinely check or document hospice visits in the resident's records. The RN stated it was not her responsibility to monitor the hospice binder, and the LVN indicated she was unaware of previous hospice visits if she was not on duty. Both acknowledged the importance of documentation and the potential for missed care if visits were not tracked. The hospice case manager also confirmed that while she documented visits in the hospice provider's electronic health record, she did not always sign the facility's hospice binder due to its unavailability and did not record which facility nurse she checked in with during visits. Further, the hospice patient care manager stated that all hospice disciplines were required to sign in the hospice binder after each visit, and that case managers were responsible for ensuring all scheduled visits were completed and documented. The facility's DON expected charge nurses to document hospice visits and to check the hospice binder for compliance. Despite these expectations, there was a lack of documented evidence in the hospice binder to show that the resident received the ordered hospice services, and facility leadership acknowledged these findings during the survey.
Failure to Develop and Implement Care Plan for Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident who frequently refused multiple aspects of care. The resident, who was admitted with a surgical wound and had the capacity to make decisions, repeatedly refused activities of daily living (ADL) care, dialysis, medications, repositioning, and skin and wound assessments. These refusals were documented in the medical record and confirmed by both the Wound Care Nurse and the Director of Nursing (DON). Despite the resident's ongoing refusals, the care plan did not address these behaviors or outline strategies to manage or respond to the refusals. The lack of a care plan problem related to the resident's refusals resulted in the surgical wound with sutures not being assessed, monitored, or cared for until several months after admission. The wound and sutures were only discovered and addressed after a significant delay, during which the resident also developed other unrelated wounds. Interviews with facility staff, including the Wound Care Nurse and the DON, confirmed that the resident's refusals were not incorporated into the care plan. The DON acknowledged that the absence of a care plan addressing the refusals contributed to the missed assessment and care of the surgical wound. The deficiency was verified through medical record review, staff interviews, and direct observation of the resident refusing care.
Plan Of Correction
F0656 - Develop and Implement Comprehensive Person-Centered Care Plan Immediate Corrective Action: On September 2, 2025, a treatment care plan was developed for Resident #10 for multiple refusals. Residents Affected: On September 2, 2025, the RN Supervisor reviewed all residents with refusals to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3, 2025, on the process for developing, reviewing, and updating care plans for refusals care plan. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and reassess the care plan for a resident following two separate fall incidents. The resident, who had a documented risk for falls and a care plan addressing this risk, experienced falls on two occasions, resulting in new skin tears during one of the incidents. Despite these events, the care plan was not updated to reflect the resident's current status or to reassess the effectiveness of existing interventions, as required by facility policy and federal regulations. Interviews with registered nurses and the Director of Nursing confirmed that the care plan was not revised after the falls, and that it should have been updated to guide staff in providing appropriate care. The facility's policies also require documentation and care plan updates following such incidents, but these actions were not taken in this case.
Plan Of Correction
F0657 - Care Plan Timing and Revision Immediate Corrective Action: On 09/25/2025 and 09/26/2025, a fall care plan was developed and updated for Resident #08. Residents Affected: On 09/25/2025, the RN Supervisor reviewed all residents with falls to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 17th, 2025, on the process for developing, reviewing, and updating care plans for falls. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and recent falls during IDT meetings. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Develop Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the specific care needs of a resident who was admitted with a surgical wound. Upon admission, the resident had a surgical incision on the left lateral thoracic region with three sutures, as documented in the transfer orders from the acute care hospital. These orders included instructions to follow the wound team's recommendations and standard nursing protocols for wound care. Despite these clear instructions, the baseline care plan for the resident did not include a problem or interventions related to the surgical wound. There was no evidence that the facility assessed, monitored, or provided wound care for the surgical incision within 48 hours of admission, as required by regulation. The omission was confirmed during interviews and medical record reviews with the Director of Nursing (DON) and the Administrator, who both verified that the baseline care plan did not address the resident's surgical wound with sutures. As a result, the resident's care needs related to the surgical wound were not met from the time of admission until several months later. This failure was identified through medical record review and staff interviews, and it was determined that the lack of a baseline care plan for the surgical wound had the potential to affect the resident's well-being.
Plan Of Correction
F0655 - Baseline Care Plan Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites from wound report to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Assess and Provide Care for Surgical Wound with Sutures
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and provide care for a surgical incision with sutures for one resident admitted from an acute care hospital. The resident was admitted with a surgical incision on the left lateral thoracic region, which had three stitches and an intact dressing. Transfer orders from the hospital specified that wound care should follow current recommendations and standard nursing protocols. The admission skin assessment documented the presence of the surgical incision and dressing, but subsequent progress notes indicated that the skin issue had not been evaluated. From admission until several months later, there was no evidence that the facility assessed or monitored the surgical wound, nor was there a baseline care plan developed to address the wound or the presence of sutures. The omission persisted until the resident's outpatient dialysis clinic notified the facility about the sutures, prompting the wound care nurse to assess the site and remove the stitches. Interviews confirmed that the wound was in a location easily visible during routine care, and the resident required maximum assistance with activities of daily living, making the oversight notable. The Director of Nursing verified that licensed nurses were required to perform full skin assessments on admission, readmission, and weekly if no concerns were present, and that direct care staff were expected to assess skin during bathing, changing, or repositioning. The facility's failure to follow these protocols resulted in a delay in identifying and providing care for the surgical incision and sutures, as confirmed by both the DON and the administrator.
Plan Of Correction
F0684-- Quality Of Care Immediate Corrective Action: On 09/02/2025, treatment care was initiated immediately for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0684
Failure to Complete Post-Fall Assessments and Notifications
Penalty
Summary
The facility failed to provide necessary care and services to a resident who experienced two falls, as required by federal regulations and the facility's own policies. After the resident was found on the floor on two separate occasions, there was no documented assessment of the resident's change in condition, no neurological assessments, and no post-fall assessments completed. Additionally, the required 72-hour post-fall monitoring and documentation were not performed following either incident. Pain and skin assessments were also missing after the respective falls, and there was no evidence of an interdisciplinary team (IDT) review or update to the resident's care plan. The facility did not notify the resident's physician or the resident's representative after the falls, as mandated by policy. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these notifications and assessments were not completed. The DON and staff provided inconsistent definitions of what constituted a fall, with some initially not considering the incidents as falls due to the resident's behavior of getting up unassisted, despite later acknowledging that being found on the floor should be classified as a fall. Review of the facility's policies indicated clear requirements for post-fall assessment, documentation, and notification, which were not followed in these cases. The lack of proper documentation and follow-up assessments had the potential to delay identification and treatment of possible fall-related injuries and posed a risk for additional falls and injury to the resident. The findings were verified through medical record review and staff interviews, which confirmed the absence of required documentation and follow-up actions after the resident's falls.
Plan Of Correction
F0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrective Action: On 09/23/2025 and 09/25/2025, change of condition, neurocheck, care plan, post fall assessment initiated and MD and responsible party was notified. Residents Affected: On 09/23/2025, the RN Supervisor reviewed all residents with falls to ensure that change of condition, neurochecks, care plan, post fall assessment initiated and MD and responsible party was notified. No other residents were affected. Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0695 - Respiratory/Tracheostomy Care and Suctioning Immediate Corrective Action: On September 19th, 2025, the RN Supervisor changed the tubing for Resident #4's CPAP and properly labeled/stored the tubing.
Failure to Provide and Maintain CPAP Therapy for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents requiring CPAP therapy. For one resident with a physician's order for nightly CPAP use due to sleep apnea, the CPAP mask was observed on the floor, and there was no designated bag available in the room for sanitary storage. During an interview, an LVN confirmed the absence of a storage bag and acknowledged the infection risk associated with the mask being on the floor. The Director of Nursing also verified that the mask should not have been on the floor. For another resident, also with a physician's order and care plan for nightly CPAP use to treat obstructive sleep apnea, there was no CPAP machine present in the room. The resident reported not having received a CPAP machine since admission. Both an RN and the Director of Nursing confirmed the absence of the CPAP machine and that the resident was not receiving the prescribed treatment. These findings were acknowledged by facility leadership.
Plan Of Correction
Residents Affected: On 9/19/2025, all residents on CPAP were observed by the RN Supervisor to verify compliance. No other residents were affected. Corrective Action: Licensed staff were inservice re-educated on respiratory care procedures by the DON on 09/19/2025 on the facility policy and procedure, for oxygen administration/CPAP. Monitoring of Corrective Action: The DON or their designee will perform daily room rounds to verify compliance with the CPAP administration policy and procedure. Identify deficient practices will be corrected by the DON or designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- F0698-Dialysis Care and Services Immediate Corrective Action: Resident #10, #18-DON began inservicing licensed nurses on proper documentation pre and post dialysis, correct access site on 09/23/25, and ensuring that resident receive dialysis treatment from outpatient center 09/23/25. Resident #10-DON began inservicing licensed nurses on proper documentation of the dialysis site 09/23/25. Residents Affected: All dialysis residents were assessed and their communication forms were completely filled out with accurate site and information on 09/23/25. No other residents were affected. Corrective Action: Nursing staff were re-educated / in-service by the DON on 09/23/2025 on policy and procedure for dialysis care, ensuring that the resident receive dialysis treatment from outpatient center and proper documentation of the dialysis site. Monitoring of Corrective Action: The DON or their designee will perform weekly audits on dialysis residents to ensure policy and procedure on dialysis care is followed and proper documentation for the access sites, monitoring to ensure that resident receive dialysis treatment from outpatient center.
Failure to Provide and Document Dialysis Care as Ordered
Penalty
Summary
The facility failed to ensure that dialysis care was provided according to physician orders and professional standards for two residents. For one resident, the facility did not ensure that the resident received scheduled hemodialysis treatments at an outpatient dialysis center as ordered by the physician. Medical record reviews and staff interviews confirmed that the resident did not leave the facility for dialysis on multiple scheduled days, and the dialysis center administrator verified that the resident was not dialyzed during the relevant period. The facility's own investigation concluded that the resident missed scheduled dialysis sessions, and the reason for the missed appointments was not documented, though it was noted that transportation could not be arranged. For another resident, the facility failed to accurately assess and document the resident's dialysis access site as ordered by the physician. The resident, who had end-stage renal disease and a Perma-Cath in the left thigh, had physician orders and communication records incorrectly specifying the access device as a Port-A-Cath, which is a different type of vascular access typically implanted in the chest wall. The DON confirmed that the physician's order was incorrect and that the resident's actual access was a Perma-Cath. These failures resulted in the residents not being provided with appropriate care and treatment as ordered by their physicians. The facility's policies required nursing care for dialysis residents to be provided in accordance with physician orders, but this was not followed in these cases, as evidenced by the missed dialysis treatments and incorrect documentation of dialysis access.
Plan Of Correction
Identified deficiencies will be corrected immediately by designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Deficiencies in Nursing Competency and Medication Administration
Penalty
Summary
The facility failed to ensure that both licensed nurses and CNAs possessed and demonstrated the required competencies and skill sets necessary to provide safe and effective nursing care, specifically in the area of skin assessment. One resident was admitted with a surgical incision that required monitoring and care, as indicated in the transfer orders and admission skin assessment. Despite the presence of a visible surgical wound, the facility staff did not assess, monitor, or provide care for the wound from the date of admission until several months later, when the issue was identified by an outside dialysis clinic. Multiple staff members, including licensed nurses and CNAs, provided care to the resident during this period but failed to perform the required skin assessments or document the condition of the wound. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the facility's competency checklists for both CNAs and licensed nurses did not include skin assessment, even though it was a required competency. Both the DSD and DON acknowledged that the omission of skin assessment from the competency evaluations contributed to the failure of multiple staff members to assess and document the resident's surgical wound as required. The lack of proper assessment and documentation persisted until the wound was finally evaluated and the sutures were removed months after admission. Additionally, the facility failed to follow physician's orders regarding medication administration for another resident. Specifically, the facility did not administer lidocaine patches as prescribed for pain management. Review of facility policies and procedures confirmed that medications are to be administered only upon clear, complete, and signed orders from authorized prescribers, and in accordance with written orders. However, the facility did not comply with these requirements, resulting in the resident not receiving the ordered medication.
Plan Of Correction
F0726 - Competent Nursing Staff Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. All Licensed Competency Skill Checks were initiated immediately. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites, and skills competency. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting the same week to verify compliance and continue with skill competency every month. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- P0755 - Pharmacy Services/Procedures/Pharmacist/Records Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR for Resident #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR and ensured all Lidocaine patches were administered. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). Monitoring of Corrective Action: The DON or their designee will perform weekly med pass observations for 12 weeks, focusing on safe practices and documentation accuracy, and review medication disposition record logs to verify compliance. Visual checks will be conducted to ensure patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Administer and Accurately Document Pain Medication
Penalty
Summary
Resident 11, who had the capacity to make medical decisions, was readmitted to the facility and had physician orders for two types of lidocaine patches: Asperflex Lidocaine 4.0% to be applied to the lower back and Lidoderm 5% to be applied to the right hip, both for pain management. The facility's policies required medications to be administered as prescribed, documented immediately after administration, and not pre-poured or shared between residents. Medical records indicated that the patches were documented as administered and removed at scheduled times on multiple days. However, direct observation and interviews revealed that Resident 11 did not receive the lidocaine patches on two consecutive days, despite documentation on the MAR indicating otherwise. The DON confirmed that the patches were not applied and that the medication cart still contained the full supply of patches, which had not been refilled or used as documented. The discrepancy was further verified by pharmacy records and staff interviews, confirming that the resident did not receive the prescribed pain management as ordered.
Plan Of Correction
- Disposition record logs to verify compliance. Visual checks that patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. For one resident, a physician's order required monitoring and documentation of the number of times the resident attempted to get up unassisted each shift. However, the Monitor Record for this resident had missing entries on several dates and inaccurately recorded zero incidents on days when the resident had actually gotten up unassisted and experienced unwitnessed falls. The Director of Nursing (DON) and a registered nurse confirmed these omissions and inaccuracies, acknowledging that the documentation was not completed as required. For another resident, there were physician's orders for the application and removal of two different lidocaine patches for pain management. The Medication Administration Record (MAR) indicated that the patches were applied and removed as ordered on specific dates and times. However, during an interview, the resident reported not receiving the patches on two days, and the DON confirmed that the patches had not been applied despite being documented as administered on the MAR. These documentation failures were verified through interviews, record reviews, and observations. The facility's own policies required accurate and timely documentation of clinical findings and medication administration, but these were not followed in the cases reviewed. The deficiencies had the potential to result in unmet care needs for the affected residents due to inaccurate medical records.
Plan Of Correction
F0842-Resident Records - Identifiable Information Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR and monitoring getting up unassisted for Resident #8 & #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR to ensure all Lidocaine patches were administered, complete, accurate, and properly stored. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). All resident records were audited by the Medical Records Director and DON to verify accuracy, completeness, and proper storage on 09/04/2025. Monitoring of Corrective Action: The DON or their designee will audit 5 random resident records weekly for 4 weeks, then Q2 monthly for 6 months to ensure compliance, focusing on safe practices, documentation accuracy, and proper storage and handling of medication. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed.
Failure to Document Discharge Instructions for Resident with Complex Care Needs
Penalty
Summary
The facility failed to ensure that discharge instructions were properly documented for one of two sampled residents reviewed for discharge. The resident, who had multiple diagnoses including obstructive uropathy, s/p left nephrostomy, AKI on CKD 3, bladder cancer, hypertension, CVA, and chronic CHF, was determined to have the capacity to understand and make decisions. The resident's Post Discharge Plan of Care and Summary lacked entries in sections related to Foley catheter care and other special care instructions. Additionally, the Skilled Evaluation Notes for several days prior to discharge did not contain any documentation under the Education/Notification section. Interviews with the DON and DSD confirmed that there was no documentation in the resident's progress notes, Post Discharge Plan of Care and Summary, or Skilled Evaluation Notes indicating that the resident was provided with education or instructions regarding their specific care needs, such as Foley catheter and nephrostomy care, prior to discharge. Both the DON and DSD acknowledged that this information should have been documented if provided. The Administrator and DON verified these findings during the review.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a conflict between two residents escalated, resulting in one resident pushing an over-bed table that struck the other resident in the head. Prior to the incident, there were documented concerns: one resident had expressed unhappiness with his roommate several days earlier, and staff had observed ongoing verbal aggression between the two. Despite these warning signs, the facility did not take action to separate the residents or address the escalating conflict. Medical record reviews and staff interviews revealed that the resident who was ultimately injured had repeatedly requested a room change and informed both the charge nurse and CNAs about the ongoing issues. Staff, including CNAs and LVNs, were aware of the residents' verbal altercations and the request for a room change, but no action was taken to separate them. On the day of the incident, staff observed the residents engaging in verbal aggression, with one resident making a direct threat to harm the other. The residents were not separated at this point, and the situation escalated to physical violence. After the altercation, the injured resident was assessed and found to have a small movable mass with minimal redness and flaky skin on the head, and later reported ongoing headaches. Interviews with staff and the social services director confirmed that the concerns about the residents' compatibility and safety were not communicated or addressed in a timely manner. The facility's policy required immediate separation of residents in such situations, but this was not followed, resulting in harm to the resident.
Failure to Interview Key Witness in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents who had a verbal and physical altercation in their shared room. According to the facility's policy, all individuals who may have knowledge of the incident, including those in the vicinity at the time, should be interviewed as part of a comprehensive investigation. However, the facility's investigation file showed that only the involved residents and staff were interviewed, and the roommate who was present in the room during the incident was not interviewed. This omission was confirmed through interviews with the Social Services Director (SSD) and the Administrator, both of whom indicated that they did not see the need to interview the roommate. Further review revealed that the roommate, when later interviewed by surveyors, stated he was present in the room during the altercation, heard the commotion, and could provide relevant information about the incident, even though his curtain was closed. The facility's failure to interview this roommate, as well as other potentially affected residents, resulted in an incomplete investigation of the abuse allegation, contrary to the facility's own policies and procedures.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement a systematic approach to monitor and address significant weight loss in two residents, resulting in deficiencies related to nutrition and hydration status. For one resident with diagnoses including enterocolitis due to clostridium difficile, anemia, and gastro-esophageal reflux disease, there was a severe weight loss of 51 lbs. (23.29%) over six months, 14 lbs. (6.39%) in one month, and 30 lbs. (14%) in another period. Despite physician orders for nutritional supplements, snacks, and weekly weights, the resident was not assessed and monitored by the interdisciplinary team (IDT) in a timely manner. The care plan identified the risk for weight loss, but interventions such as IDT assistance during meals and monitoring were not effectively implemented. Additionally, a Change of Condition (COC) was not initiated when severe weight loss occurred, and there was no documentation of physician or legal representative notification at those times. Another resident with a diagnosis of dysphagia experienced a significant weight loss of 17 lbs. (12.14%) in one month. The care plan included interventions such as multivitamin/mineral supplements, a protein supplement beverage, and weekly weights for three weeks. However, the resident's weights were not monitored as ordered, with a 14-day gap between recorded weights. The resident reported being informed of weight loss but was unaware of the extent and stated there was no discussion about the facility's response to the weight loss. The care plan did not reflect updated goals or interventions regarding the risk for weight loss, and the required monitoring was not completed as ordered by the physician. Interviews with facility staff, including the Registered Dietitian (RD) and Director of Nursing (DON), confirmed that the process for addressing significant weight changes was not followed. The RD acknowledged that the physician was not notified of the severe weight loss, and the DON verified that a COC, including physician and legal representative notification, RD consult, and IDT evaluation, should have been initiated immediately upon identification of significant weight loss. The administrator and DON were made aware of these findings.
Inaccurate Medical Record for Enteral Feeding
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one of the sampled residents, Resident 2. The deficiency was identified through interviews, medical record reviews, and facility policy and procedure (P&P) reviews. The facility's P&P for medication orders and administration required clarification of orders, proper documentation, and transcription of new orders on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, there was a discrepancy in the documentation of enteral feeding orders for Resident 2. The Order Summary Report indicated an order for Jevity 1.5 enteral feeding, but the MARs for January and February showed a different formula, [NAME] Farms 1.4, being administered. This discrepancy was not clarified or corrected in the MAR. Interviews with facility staff revealed that LVN 1 administered Jevity 1.5 but documented it under the [NAME] Farms 1.4 order, failing to clarify the orders. RN 1 confirmed the facility did not have [NAME] Farms 1.4 and had received an order for Jevity 1.5, but the MAR was not updated accordingly. The RD confirmed that Jevity 1.5 was equivalent to [NAME] Farms 1.4, but the facility did not carry the latter. The DON verified these findings, indicating a lapse in ensuring accurate medical records and proper communication among staff regarding medication orders and administration for Resident 2.
Deficiencies in Catheter Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling urinary catheters. For the first resident, the facility did not ensure that the urinary catheter drainage bag was kept off the floor, which is against the CDC's guidelines for preventing catheter-associated urinary tract infections (CAUTI). Observations on two consecutive days showed the drainage bag lying on the floor, and interviews with nursing staff confirmed that this was not in compliance with proper catheter maintenance procedures. Additionally, there was no care plan developed to address the resident's UTI and antibiotic treatment. For the second resident, the facility failed to notify the physician of a change in condition due to frequent leakage of the indwelling urinary catheter. The resident experienced frequent catheter dislodgement and leakage, which required the catheter to be changed more often than usual. Despite the resident's history of using a specific catheter size, the facility did not clarify the appropriate size with the physician, leading to the use of a different size catheter. Interviews with the resident and nursing staff confirmed that the physician had not been informed of the frequent leakage or the change in catheter size. These deficiencies indicate a lack of adherence to established protocols for catheter care and communication with physicians regarding changes in resident conditions. The facility's failure to maintain proper catheter hygiene and notify the physician of significant changes posed a risk for adverse complications related to catheter use.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's POLST, which indicated a Do Not Attempt Resuscitation (DNR) order. This failure occurred when the resident was found unresponsive and without a pulse, and CPR was initiated despite the resident's documented wishes. The POLST was not immediately accessible, leading to the initiation of resuscitative measures contrary to the resident's directives. The resident had the capacity to make medical decisions, as noted in their health and physical examination. During the incident, a Licensed Vocational Nurse (LVN) stated that CPR was continued even after the POLST was found because a family member requested it. The Director of Nursing (DON) confirmed that the POLST indicated a DNR order and acknowledged that it should have been followed. The facility's policy and procedure on advance directives required that such documents be easily accessible in emergencies, which was not adhered to in this case.
Deficiency in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure the nutritive content and palatability of pureed food for residents on the American menu. Observations revealed that pureed vegetables were cooked and held in a hot oven for more than one hour before meal service, which could lead to a reduction in essential nutrients such as water-soluble vitamins. The facility's policy on puree food preparation requires that food be prepared in a way that conserves nutritive value, flavor, and appearance. However, the pureed green beans were cooked, pureed, and then kept in a hot oven for an extended period, contrary to these guidelines. The Registered Dietitian (RD) Consultant confirmed that the pureed foods should be cooked to preserve their nutritive value. Additionally, the facility did not ensure that the bread served was palatable, as evidenced by a test tray inspection where the breadstick was found to be crusty and hard to chew. This inspection was conducted with the Kitchen Supervisor and RD Consultant, who verified the findings. The facility's menu for the day included vegetable lasagna, sauteed mixed squash, breadstick and butter, peach dump cake, and a choice of beverage. The hard texture of the breadstick could potentially affect the residents' ability to consume the meal comfortably.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. Specifically, the facility did not ensure proper labeling and dating of opened food items in the freezer. During an inspection, it was found that a plastic bag of frozen cookie dough, a bag of potato hash browns, and a bag of frozen waffles were not labeled with an open date and were observed to have freezer burn. The Kitchen Supervisor acknowledged these findings and confirmed that the items were no longer suitable for consumption. Additionally, the facility did not ensure that food preparation equipment was properly air-dried before storage. During the kitchen tour, five cutting boards were found stored wet in the cutting board rack, which the Kitchen Supervisor confirmed were not air-dried properly. Furthermore, one cutting board was heavily marred with knife marks, making it difficult to clean and sanitize, which could lead to the accumulation of pathogenic microorganisms. The Kitchen Supervisor acknowledged this issue and stated that the equipment would be discarded.
Failure to Conduct Bed Safety Inspections and Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for safety, specifically failing to assess the risk of entrapment for several residents. Observations and medical record reviews revealed that the facility did not perform routine bed inspections or entrapment assessments for residents using side rails or halo grab bars. The facility's policy required semi-annual assessments for entrapment risks, but these were not conducted for the sampled residents, leading to potential safety hazards. The Maintenance Director admitted to not conducting routine bed inspections and was unaware of the different zones of entrapment that needed assessment. The Bed System Measurement Device Test Results Worksheets for the residents showed that zones 4, 6, and 7 were not assessed for entrapment risks. Interviews with staff, including CNAs and LVNs, confirmed that entrapment assessments were not performed, and the maintenance department was only called for installation purposes. Residents involved in the deficiency included those with severe cognitive impairments, such as Alzheimer's dementia, and others who were non-ambulatory or had difficulty with bed mobility. Despite having care plans that addressed the use of bed rails and halos for mobility and repositioning, the facility failed to ensure these devices were safe and properly assessed for entrapment risks, as required by their policies and manufacturer guidelines.
Deficient Call Light System in Multiple Rooms
Penalty
Summary
The facility failed to ensure that the call light system was fully operational in several rooms, which could lead to delayed assistance for residents. Specifically, the call lights in Room N and Room O did not light up or sound at the nursing station, and the call light in Resident 16's room was dim and not audible. These deficiencies were confirmed through observations and interviews with staff, including the Assistant Director of Nursing (ADON), Certified Nursing Assistants (CNAs), and Registered Nurses (RNs). The facility's policy and procedure (P&P) required prompt reporting and documentation of defective call lights, but this was not consistently followed. In Room N, the restroom call light failed to light at the door and did not sound at Nursing Station B's call panel. This was verified by CNA 8 and RN 1, who noted the importance of a functioning call light system for both resident and staff safety. Similarly, in Room O, the restroom call light did not light or sound at the nursing station, and attempts to fix the issue by changing the light bulb were unsuccessful. The Maintenance Director acknowledged the need for immediate repairs. Additionally, the call light system for Rooms A to M at Nursing Station A had no audible sound, although the lights were visible on the panel. This issue was observed by CNAs and Licensed Vocational Nurses (LVNs), who noted that the problem had persisted for several days without being reported to the maintenance department. The lack of an audible alert could result in staff not noticing when residents require assistance, especially when they are not present at the nursing station. The facility's failure to maintain a fully functional call light system poses a risk to resident safety and care.
Failure to Coordinate and Document Medical Appointments
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 48, by not coordinating and following up on required medical appointments as per transfer orders from an acute care hospital. The resident was supposed to attend appointments with an infectious disease physician and an oncologist, but there was no documentation that these appointments were completed. The medical record indicated that the appointment with the infectious disease physician was marked as completed, yet there was no evidence that the resident attended. Additionally, the appointment with the oncologist was discontinued without being scheduled or followed up. Interviews with facility staff, including an RN, the SSD, and the DON, confirmed the lack of documentation and follow-up regarding these appointments. The SSD mentioned transportation issues as a reason for missing the infectious disease appointment, and the DON noted that the oncology appointment was not scheduled due to billing issues. However, there was no documentation explaining these issues or any attempts to resolve them, leading to a failure in ensuring the resident received appropriate medical care and treatments.
Failure to Renew Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to properly obtain informed consent for the use of psychotropic medications for a resident who lacked the capacity to make decisions. The resident, who was admitted and readmitted to the facility, was prescribed Seroquel for psychosis. However, the informed consent for this medication was not renewed as required by the Nursing Facility Resident Informed Consent Protection Act of 2023, which mandates that consent be renewed every six months. The last documented consent was obtained more than six months prior to the new order for Seroquel. During interviews and medical record reviews, it was confirmed by both an LVN and the DON that there was no updated informed consent for the use of Seroquel. This oversight meant that the resident's responsible party was not informed about the medication and its potential side effects, as required by the facility's policy and the new legislative requirements. This deficiency was identified during a survey and cross-referenced to F758.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, specifically regarding the accessibility of call lights. During an initial tour, it was observed that Resident 124's call light was clipped to the wall panel and not within reach, despite the resident's ability to use it. Resident 124, who was admitted to the facility with the capacity to make decisions and communicate effectively, complained of leg pain during the observation. The inaccessibility of the call light could potentially delay the resident's ability to request assistance. Similarly, Resident 38 was found with the call light button underneath his pillow, making it unreachable. This resident, who had moderately impaired cognition but no physical impairments to the extremities, required substantial assistance with daily activities. The call light was not repositioned after a physical therapy session, as confirmed by a CNA. On a subsequent observation, the call light remained out of reach, and the resident expressed a need for assistance with moving the bedside table and obtaining water. These observations indicate a failure to ensure that call lights were accessible to residents, potentially impacting their ability to receive timely care.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of four residents, leading to deficiencies in individualized care. Resident 116 had a physician's order for the treatment of a left heel pressure injury, but the care plan did not include this issue, as confirmed by an LVN during a medical record review. This oversight was contrary to the facility's policy on pressure injury prevention and management, which mandates the development of care plans with measurable goals for such conditions. Resident 120's care plan did not address the physician's orders for fluid restriction and the administration of ertapenem sodium intravenously for pneumonia and empyema of pleura. This was verified by an RN during a medical record review. The absence of these critical care components in the care plan posed a risk of not providing appropriate treatment for the resident's conditions. Additionally, Resident 46's care plan failed to address hearing difficulties and ear treatments, despite physician's orders for ear drops and irrigation. This was confirmed by both an LVN and the DON during separate reviews. Furthermore, Resident 374's care plan did not include droplet isolation precautions, even though there were physician's orders for such measures due to Acinetobacter species infection. The DON verified the lack of documentation for these precautions in the care plan.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in wound management and pressure injury prevention. For Resident 103, the facility did not adhere to its policy and procedure for clean dressing changes, which is designed to minimize infection and cross-contamination. During a wound care observation, a Licensed Vocational Nurse (LVN) did not use a protective barrier cloth or pad, resulting in the resident's sacrococcyx pressure injury coming into contact with a soiled diaper. This oversight occurred despite the presence of exudate on the dressing and diaper, and the LVN admitted to not typically using protective measures during treatments. The Director of Nursing (DON) was informed and acknowledged these findings. For Resident 116, the facility did not follow the physician's order to offload and elevate the resident's bilateral lower extremities to maintain skin integrity. Observations revealed that the resident's heels were resting on the mattress, contrary to the order to offload them using pillows or assistive devices. Both an LVN and a Certified Nursing Assistant (CNA) confirmed that the resident's heels were not properly elevated. Additionally, the resident's care plan did not address the care of a left heel pressure injury. The DON was informed of these findings and acknowledged the issues.
Failure to Document PICC Line Measurements
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous accesses for a resident, specifically regarding the management of a PICC line. The facility's policy and procedure required an assessment of the venous access site and dressing change upon admission and every seven days, as well as monitoring for complications. However, the medical record for a resident with a PICC line did not include documentation of the external catheter length and arm circumference measurements upon admission, as required by the physician's orders. Observations and interviews revealed that the resident had a PICC line with a transparent dressing, but the necessary measurements were not documented in the medical record. Both a registered nurse and the Director of Nursing confirmed the absence of these measurements, which were supposed to be recorded upon admission and with every dressing change. This oversight had the potential to delay the identification of catheter-related complications for the resident.
Deficiencies in Respiratory Care Documentation and Equipment Storage
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents, leading to deficiencies in their care. Resident 374 was observed receiving oxygen via nasal cannula, but the Yankauer suction was improperly stored in an open drawer without a set-up bag, and there was no documentation of oxygen saturation levels or oxygen administration in the MAR. Despite having orders to maintain oxygen saturation levels above 92%, these were not recorded, and the resident was unsure of the need for oxygen, indicating a lack of communication and documentation. Resident 95 also experienced similar issues, with observations showing the resident receiving oxygen without corresponding documentation in the MAR. The resident's oxygen saturation levels were not recorded, despite physician orders to maintain levels above 92% for shortness of breath. Interviews with staff confirmed the lack of documentation, and the DON acknowledged that the oxygen saturation levels and administration should have been recorded. Resident 54's care was compromised by improper storage of the nasal cannula tubing, which was found on the floor and bed, posing a risk of contamination. The resident's oxygen therapy was not documented in the MAR, and there was no record of oxygen saturation levels, despite physician orders to maintain levels above 96%. Staff interviews confirmed these findings, and the DON verified the lack of documentation, highlighting a systemic issue in maintaining accurate records for respiratory care.
Failure to Document Controlled Medications
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medications for a resident, which could lead to medication diversion. Specifically, the facility's policy and procedure for controlled medications required that when a controlled medication is administered, the licensed nurse must immediately document the date, time, amount administered, and their signature on the accountability record, as well as their initials on the Medication Administration Record (MAR). However, for a resident, the documentation for two controlled medications, morphine sulfate and lorazepam, was incomplete. The Narcotic and Controlled Substances Count Sheet did not have the required nurse's signature for the removal of these medications on the specified date and times. During an interview and review of the Narcotics and Controlled Substances Count Sheets, the Director of Nursing (DON) confirmed the findings. The DON stated that it was expected for the nurse to record and sign on the count sheet after removing controlled drugs. The deficiency was acknowledged by both the DON and the Administrator during the surveyor's review. This lack of documentation could potentially lead to medication diversion, as the accountability for the controlled substances was not maintained as per the facility's policy.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically Seroquel and sertraline, by not completing the required monthly behavior summary. The resident, who lacked the capacity to understand and make decisions, was prescribed Seroquel for psychosis and sertraline for depression. However, the facility did not document the target behaviors for these medications in the months leading up to the survey, as required by their policy. Additionally, the facility did not monitor the behavior manifestations and side effects associated with the use of Seroquel, sertraline, and Ativan, which were prescribed to the resident. Interviews with facility staff, including an LVN and the ADON, confirmed the absence of documentation for behavior monitoring and side effects. The DON was also informed and verified these findings, indicating a lapse in adherence to the facility's policy on psychotropic medication management.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 16%. During a medication administration observation, LVN 6 was found to have made several errors. LVN 6 did not check Resident 10's heart rate before administering metoprolol, a medication for hypertension, which was against the physician's order to hold the medication if the heart rate was less than 60 beats per minute. Additionally, LVN 6 did not administer Colace, a stool softener, as ordered for bowel management, and failed to give metformin and ferrous sulfate with meals as prescribed. Resident 10's medical records indicated specific physician orders for medication administration that were not followed by LVN 6. These included administering metoprolol with specific parameters, and ensuring certain medications were taken with meals. The Director of Nursing acknowledged these findings and confirmed that medications should be administered as ordered by the physician, emphasizing the importance of following prescribed parameters to avoid potential negative outcomes for residents.
Failure to Check Heart Rate Before Administering Metoprolol
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of metoprolol, a blood pressure medication. During a medication administration observation, a Licensed Vocational Nurse (LVN) did not obtain the resident's heart rate (HR) before administering metoprolol, despite a physician's order requiring the HR to be checked and the medication to be held if the HR was less than 60 beats per minute. This oversight was confirmed during an interview with the LVN, who acknowledged not checking the HR prior to administering the medication. The Director of Nursing (DON) was informed of the findings and acknowledged that medications should be administered as per the physician's orders, with staff expected to follow the specified parameters. The physician's order for the resident included instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg or if the HR was less than 60 beats per minute. The failure to adhere to these parameters had the potential to cause the resident's heart rate to drop too low, which could negatively affect the resident's health.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed in several instances. In Medication Room B, a multi-dose vial of testosterone cypionate for a resident was found without an opened date or nurse's initials, which is against the facility's policy. The Licensed Vocational Nurse (LVN) confirmed the oversight, and the Director of Nursing (DON) acknowledged the findings, indicating a lapse in adherence to medication labeling protocols. In Medication Room A, medications belonging to discharged residents were not placed in the designated location for destruction. Instead, they were found mixed with stock supplies, which is contrary to the facility's policy. The LVN confirmed that the medications should have been disposed of or placed in the designated area for destruction, and the DON acknowledged the failure to follow the proper process for handling medications of discharged residents. Additionally, in Medication Cart A, a tube of hydrocortisone cream was improperly stored with oral medications, and vials of Mucomyst were not refrigerated as required. The LVN confirmed these storage errors, and the DON acknowledged that external medications should be separated from oral medications and stored according to instructions. In Medication Cart C, opened tubes of topical medications were not labeled with the open date, as confirmed by the LVN and acknowledged by the DON, indicating a failure to follow labeling procedures for topical medications.
Failure to Refrigerate Opened Food Items at Resident's Bedside
Penalty
Summary
The facility failed to implement its policy and procedure regarding the safe handling and storage of food items brought in by family members or visitors for a resident. Specifically, the facility did not ensure that opened food items at the bedside of a resident were refrigerated when necessary, which could lead to unsafe food handling practices. The policy, revised in September 2023, allows residents to have food brought in by family or visitors, but requires that food be handled safely. The policy specifies that non-refrigerated manufactured food items may be kept in the resident's room in a lock-tight container provided by the resident. During multiple observations over several days, various opened food items, including strawberry jam, pickles, Gatorade, baby ribs sauce, and a tub of I Can't Believe It's Not Butter, were found at the resident's bedside cabinet. These items were not refrigerated as required. Interviews with a CNA and an RN confirmed these findings, and it was noted that the resident had the capacity to understand and make decisions. The resident stated that they would ask staff to refrigerate items that needed refrigeration, but this was not consistently done, leading to a potential risk of foodborne illness.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its Water Management Program, particularly in the laundry room, and did not maintain a clean environment in the clean linen area. The Water Management Program lacked documentation of routine monitoring and testing, including quarterly checks of water heaters and HVAC systems for leaks, stagnant water, or biofilm. The Maintenance Director admitted to not documenting these routine checks, and the Administrator confirmed the logs were incomplete, with no record of the last Legionella test results. The facility also failed to implement proper infection control practices for two residents. Resident 116, who was on contact isolation for ESBL in urine, did not have a physician's order for the isolation precaution. Additionally, a CNA failed to follow contact isolation protocols by not performing hand hygiene and not wearing a gown when entering the resident's room. The Infection Preventionist and the Director of Nursing acknowledged these lapses in protocol. For Resident 120, the facility did not follow Enhanced Barrier Precaution practices as ordered by a physician. There was no sign posted outside the resident's room to alert staff and visitors to the necessary precautions. The RN confirmed the absence of the sign and the Infection Preventionist acknowledged that the resident should have been placed on Enhanced Barrier Precaution as per the physician's order.
Deficiencies in Equipment Maintenance and Quality Control
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically regarding the glucometers used for blood glucose monitoring. The Assure Platinum blood glucose monitoring system manual requires that control solution results fall within a specified range to ensure accuracy. However, the facility's records for Medication Carts A and B showed multiple instances where the control results were out of range, and no corrective actions were recorded. For example, on several dates in July 2024, the Level 1 control results for Medication Cart A were below the acceptable range, and the Level 2 control results for Medication Cart B were significantly above the acceptable range. Despite these discrepancies, no corrective actions were taken, which was confirmed by the Director of Nursing (DON) during an interview. Additionally, the facility failed to maintain the medication refrigerator in Medication Room A properly. An inspection revealed ice buildup and a brownish stain in the freezer compartment. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) responsible for checking the refrigerator's temperature did not report these issues to the Maintenance Director. The Maintenance Director confirmed that the cleaning of medication refrigerators was not done on a routine schedule and was only addressed when reported by the nursing staff. The DON acknowledged that the medication refrigerator should be kept clean and free of ice buildup. These deficiencies indicate a lack of adherence to established protocols for equipment maintenance and quality control, potentially leading to inaccurate blood glucose readings and compromised medication storage conditions. The facility's failure to take corrective actions when control results were out of range and to maintain the medication refrigerator in a clean and functional state were acknowledged by the DON.
Failure to Honor and Document Advance Directives
Penalty
Summary
The facility failed to clearly identify and honor the current code status and advance directives for three residents, leading to potential discrepancies in their care. For Resident 99, there was a mismatch between the advance directive, which indicated a desire not to prolong life in case of incapacity, and the POLST, which showed a full code status to attempt CPR. The Social Services Department (SSD) verified this inconsistency and acknowledged that the nursing department was responsible for updating the POLST to reflect the resident's wishes. Resident 48's medical record lacked a copy of the advance directive, despite the POLST indicating that an advance directive was available and reviewed. Interviews with RN 2 and the SSD confirmed that there was no documentation of follow-up to obtain the advance directive, which should have been initiated upon admission and documented in the baseline care plan or progress notes. For Resident 24, the facility did not provide information or assistance in formulating an advance directive, as evidenced by the unsigned Advance Directive Acknowledgment Form. Interviews with the SSD and LVN 4 confirmed that the resident did not have an advance directive in the medical record, and the resident himself stated that he did not receive any information or assistance regarding advance directives.
Failure to Provide Scheduled Showers for Residents on Isolation Precautions
Penalty
Summary
The facility failed to provide the necessary activities of daily living (ADL) care and services for two residents, specifically in the provision of showers. Resident 48, who was admitted on July 1, 2024, was scheduled to receive showers twice a week but only received two showers on July 15 and July 18, 2024. Despite being on contact and droplet precautions initially, there was no documentation of shower refusals, and the resident expressed a desire for more frequent showers. The Director of Staff Development (DSD) confirmed the lack of documentation for any refusals and acknowledged the resident was not provided showers due to initial isolation precautions. Similarly, Resident 374, admitted on July 6, 2024, was also scheduled for twice-weekly showers but only received one shower on July 14, 2024. The resident was on various isolation precautions, including droplet precautions, but expressed a desire for showers, stating she had never been given one. The Infection Preventionist (IP) and Certified Nursing Assistant (CNA) confirmed that residents on droplet precautions were not provided showers, only bed baths, despite the possibility of adhering to isolation protocols to allow for showers. The Director of Nursing (DON) verified that both residents were not provided their scheduled showers, despite the facility's ability to provide showers to residents on isolation with proper precautions. The lack of adherence to scheduled shower routines for these residents, despite their ability to make medical decisions and express their preferences, highlights a deficiency in the facility's provision of ADL care.
Failure to Maintain Nutritional and Hydration Status
Penalty
Summary
The facility failed to ensure proper nutritional and hydration status for two residents, Residents 48 and 120. For Resident 48, the facility did not adhere to the Registered Dietitian's (RD) recommendations to provide two Boost VHC nutritional drinks with each meal and to discontinue health shakes. Instead, Resident 48 was inconsistently provided with one Boost VHC and other nutritional drinks, which did not meet the RD's specified caloric and protein intake needs. This inconsistency was observed during multiple meal times, and the RD's recommendations were not clarified or documented properly by the Director of Nursing (DON) or the dietary staff. Resident 48, who was on a full liquid diet due to swallowing difficulties, expressed feelings of tiredness and potential weight loss, which could impact his rehabilitation treatments. Despite the RD's recommendations being communicated to the facility's administration and nursing staff, the orders were not executed as intended, leading to a potential compromise in Resident 48's nutritional status. For Resident 120, the facility failed to monitor fluid intake while the resident was on a physician-ordered fluid restriction of 1,500 ml per day. The care plan did not address the fluid restriction, and there was no monitoring of fluid intake until a specific date, as verified by RN 2. The lack of monitoring was confirmed by the DON, indicating a failure to maintain proper hydration status for Resident 120.
Improper Trash Storage
Penalty
Summary
The facility failed to store trash in a sanitary manner, as observed during a survey. Three out of four dumpsters located outside the kitchen by the parking structure were found to be uncovered. This failure to cover the dumpsters properly had the potential to harbor pests, as it did not comply with the US Food Code 2022, Section 5-501.113, which requires receptacles and waste handling units for refuse to be kept covered with tight-fitting lids. The observation was made on 7/16/24 at 1620 hours, and the Administrator was informed of the findings. The Administrator was seen removing and flattening some boxes from the dumpsters.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS, as required. During a review of the CMS CASPER reports, it was found that the facility had triggered for extremely low staffing on weekends for the quarter from January 2024 to March 2024. In an interview conducted on July 19, 2024, at 1400 hours, the Administrator admitted that he did not submit the complete hours worked by staff to CMS. This omission posed the risk of inaccurate auditable data reporting.
Failure to Revise Care Plan for Antibiotic and Isolation Precautions
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident 116, to reflect the current antibiotic medication and contact isolation precautions. The resident was admitted to the facility and had a physician's order to administer Levaquin for a urinary tract infection (UTI) on 7/14/24. However, the care plan was not updated to reflect this change from the previously prescribed antibiotic, Cipro. Additionally, the care plan did not include the necessary contact isolation precautions for the resident, who had a urine culture showing >100,000 CFU/ml Proteus mirabilis ESBL, a pathogen that requires such precautions. During an initial tour on 7/16/24, a contact precautions sign was observed at the resident's door, indicating the need for hand hygiene and the use of gloves and gowns by staff and providers. Interviews with LVN 7 confirmed that the resident was on contact isolation for ESBL in urine and was receiving Levaquin for the UTI. However, the care plan had not been revised to reflect these changes. The Director of Nursing (DON) was informed of these findings and acknowledged the oversight.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one of the sampled residents. Resident 1, who had diagnoses including diabetes mellitus (DM), deep vein thrombosis (DVT), and May-Thurner Syndrome, was not given aspirin 325 mg daily and apixaban 5 mg twice daily as prescribed. The medical record review showed that the apixaban was only administered from 5/1 to 5/8/24, despite no order indicating it should be stopped after seven days. Additionally, the order for aspirin was not entered into the resident's medication administration record (MAR), and thus, was never administered during the resident's stay at the facility. Interviews with the Director of Nursing (DON) and the Administrator confirmed these discrepancies. The DON acknowledged that the order for aspirin was missing and should have been carried out, while the Administrator confirmed that the apixaban was incorrectly entered with a stop date. These failures resulted in Resident 1 not receiving the necessary medications as ordered, potentially impacting her treatment for DVT and other medical conditions.
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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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