Pioneers Memorial Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brawley, California.
- Location
- 320 Cattle Call Dr., Brawley, California 92227
- CMS Provider Number
- 555557
- Inspections on file
- 33
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pioneers Memorial Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with Parkinson's disease and moderate cognitive deficits, requiring maximum assistance with transfers, was left unattended on the toilet and experienced an unwitnessed fall into the bathtub. Staff failed to perform immediate post-fall neuro-checks and delayed notifying the physician and responsible party, resulting in a delayed diagnosis of multiple rib fractures. Facility policy requiring prompt post-fall assessment and notification was not followed.
A resident with Parkinson's disease, cognitive deficits, and lower extremity impairments, who required maximum assistance with toilet transfers, was left unattended in the bathroom after being assisted onto the toilet. While alone, the resident lost balance and fell into the bathtub, sustaining multiple rib fractures and pain. Staff interviews and facility documentation confirmed the resident was not provided the necessary supervision, contrary to the facility's fall management policy.
The facility failed to discard eight loaves of bread past their use by date, as observed during a kitchen tour with the Dietary Supervisor. The DS and Registered Dietitian confirmed that the bread should have been discarded to prevent potential food contamination and food-borne illness among the 72 residents.
A resident's privacy was violated when their vital signs record, containing personal and medical information, was left unattended at a nursing station. Interviews with facility staff confirmed that this was against the facility's policy on maintaining the confidentiality of medical records.
Two residents with communication difficulties were not provided with necessary communication tools, despite their care plans indicating the need for such tools due to conditions like dementia and aphasia. Observations showed these residents struggling to communicate, and both a licensed nurse and the DON acknowledged the absence of communication aids, which were essential for the residents to convey their needs.
A resident with dementia and atrial fibrillation was observed with a purplish discoloration on the elbow, which was not documented or monitored as required by the facility's policy. The Director of Nursing confirmed that the nursing staff failed to meet the expectation of documenting and monitoring skin changes, as outlined in the facility's Skin and Wound Management policy.
A facility failed to ensure a resident's gastric tube (GT) was free from air bubbles, which could lead to complications. The resident, with dysphagia and other medical conditions, had an air bubble in the GT line, observed during an interview with the Director of Staff Development. The Director of Nursing confirmed that licensed nurses should check GTs before, during, and after feeding to prevent air bubbles, as per facility policy.
A resident with heart and respiratory failure requiring continuous oxygen was found with an empty oxygen tank, which was not replaced in a timely manner. The facility's staff failed to check the oxygen tank every two hours as required, leading to a deficiency in providing safe respiratory care.
A facility failed to ensure that staff followed physician orders and had adequate competency in using low air loss mattresses and wound vacuum therapy. Observations revealed that a nurse was unaware of the manufacturer's guidelines for mattress settings, affecting four residents. Additionally, two residents received wound vacuum therapy with incomplete physician orders, which were not clarified. The DON admitted to a lack of awareness and training regarding the equipment, posing a potential risk to resident care.
The facility failed to provide a registered nurse (RN) for at least eight hours a day, affecting 99 residents. This deficiency was identified through a review of the CMS Payroll Based Journal, which showed no RN hours on multiple days. Interviews with the Director of Staff Development and the Director of Nursing confirmed the lack of RN coverage, which is required by the facility's policy.
Two residents with diabetes did not receive their Humalog insulin as ordered by their physicians, with administration occurring after meals instead of before. This deviation from the prescribed schedule was confirmed by an LPN and acknowledged by the DON, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. Two residents received medications without proper identification verification by LNs, contrary to facility policy. The residents had various medical conditions, and the LNs admitted to not using two identifiers, despite being familiar with the residents. The DON emphasized the importance of following identification procedures to prevent errors.
The facility failed to maintain infection control procedures, with a leaking water reservoir tank covered in mold and a resident's urinary catheter bag touching the floor. The water tank was not regularly inspected, leading to mold growth, while the catheter bag's improper positioning risked contamination. These lapses were acknowledged by the facility's staff.
The facility was found non-compliant with regulations limiting resident room capacity to four residents. Observations revealed two rooms could house five residents each, and seven rooms could house six residents each. No quality of care or life concerns were noted, and a waiver from CMS allowing this arrangement was recommended for renewal.
A facility failed to provide the required minimum space of 80 square feet per resident in a multiple resident room. The room measured 479 square feet and housed six residents, resulting in only 79.83 square feet per resident. Despite this, residents did not express complaints, and no quality of care or life concerns were observed. A continuance of a previously granted CMS waiver was recommended.
A resident with a left above-the-knee amputation experienced a skin tear during a transfer when a Restorative Nursing Assistant (RNA) used a Hoyer lift alone, against the facility's policy requiring two-person assistance. The resident, dependent on maximum assistance for transfers, reported discomfort during the procedure. Interviews with staff confirmed the policy and the need for two-person assistance to ensure safety.
A resident with dementia exhibited inappropriate behavior towards female residents, such as touching their arms or thighs. Despite documentation of these incidents, the care plan was not updated to guide staff on managing the behavior. Interviews with staff revealed attempts to redirect the resident, but no formal care plan was in place, contrary to facility policy.
A resident with severe cognitive impairment and diabetes experienced severe hypoglycemia and hospitalization due to the facility's failure to monitor blood sugar levels and notify the physician of low blood sugar episodes. The resident was on multiple diabetic medications, and the facility did not follow its hypoglycemia protocol, leading to the resident becoming unresponsive and being diagnosed with sulfonylurea-induced hypoglycemia and a urinary tract infection.
A resident with a history of hemiplegia, hemiparesis, cerebral infarction, and diabetes mellitus experienced a worsening of a pressure ulcer from stage II to stage III due to the facility's failure to develop a care plan and properly reposition the resident. Observations and interviews confirmed the lack of documentation and adherence to repositioning protocols.
The facility failed to provide haircuts for residents, including one with dementia, over a 10-month period due to delays in vetting a new barber/beautician after a change of ownership. This impacted residents' dignity and self-esteem, as confirmed by the Activity Director and Director of Nursing.
The facility failed to develop an effective QAPI program, leading to several deficiencies including a non-functional call light system, lack of Covid immunizations, worsening pressure ulcers, no haircuts for 10 months, unidentified hypoglycemia in a diabetic resident, and failure to perform GDRs for antipsychotic medications. The Medical Director also did not provide oversight regarding GDRs.
The facility's QAPI program failed to address several critical issues, including a non-functional call light system, lack of COVID-19 immunizations, worsening pressure ulcers, and inadequate diabetes management. The QAPI committee had not met formally since October 2023, and no Performance Improvement Plans were developed, placing all residents at risk for accidents, infections, and worsening physical and psychosocial harm.
The facility's QAPI committee failed to meet at least quarterly, with the last meeting held on 10/10/23. The Administrator acknowledged that while problems were identified, formal QA meetings were not conducted, potentially affecting resident safety and care quality.
The facility failed to develop and implement individualized care plans for three residents, including one with End Stage Renal Disease requiring dialysis, another with Diabetes Mellitus, and a third with dementia and a left humerus fracture. Interviews and record reviews confirmed the absence of necessary care plans, leading to potential risks in their care and health status.
The facility failed to consistently evaluate fall risks and conduct care conferences after falls for two residents, leading to repeated falls without new preventive measures. Additionally, the facility did not complete quarterly safety smoking evaluations for five residents, posing a risk for smoking-related injuries.
The facility failed to document non-pharmaceutical interventions or GDR for three residents reviewed for unnecessary medication. Recommendations for GDR were not acted upon, and non-pharmaceutical interventions were not attempted or documented. Missed psychotropic meetings led to a failure to monitor behaviors and follow up on medication regimen reviews.
The facility's Governing Body failed to ensure effective oversight and necessary resources for resident care services, potentially affecting the quality of care. A record review and interviews revealed that critical aspects of resident care were not adequately reviewed or discussed, and communication among facility leadership was still developing.
The facility's Medical Director failed to oversee psychotropic drug use and Gradual Dose Reductions (GDR) for 38 residents, resulting in no monthly evaluations or GDR attempts for nine months. The MD admitted that the facility had fallen behind in conducting necessary reviews and that psychotropic medications were not a primary focus since the facility changed ownership.
The facility failed to offer, re-offer, or administer COVID-19 vaccinations to 39 residents, including newly admitted and sampled residents, since reopening. Interviews and record reviews revealed that the facility had not conducted a vaccination clinic since March 2023, and the vaccination tracking log inaccurately documented refusals. The DON confirmed that the facility did not follow its policy to evaluate and offer vaccinations upon admission, potentially placing residents, staff, and visitors at risk for COVID-19 infection.
The facility failed to recognize and honor a resident's Advanced Directive indicating 'Do not resuscitate, no life supporting measures.' The resident's wishes were not communicated or documented properly, leading to a discrepancy between the physician's order and the resident's Advanced Directive. Interviews revealed that staff were unaware of the Advanced Directive in the electronic chart.
The facility failed to maintain a safe and homelike environment, with issues including peeling paint on a resident room door and exposed nails and drywall in a shower room. The DM was unaware of the peeling paint due to a lack of a maintenance log, and the ADM acknowledged the potential risks. The DM also admitted to not following up with an outside company to complete wall repairs in the shower room.
The facility failed to capture and transmit accurate MDS information to CMS for two residents, leading to potential impacts on their care. One resident's schizophrenia diagnosis was not recorded, and another resident's resuscitative wishes were not accurately documented.
The facility failed to complete a PASARR Level 2 after a resident was newly diagnosed with schizophrenia. The MDS nurse missed the diagnosis, and the Admission MDS did not include it, leading to a lack of appropriate state assessment and services for the resident.
The facility failed to update and revise care plans for two residents, one with dementia and a history of falls, and another with dementia and protein-calorie malnutrition. The care plans did not include necessary interventions, such as fall prevention measures and specific nutrition interventions, potentially impacting the residents' health status.
The facility failed to follow up on dietary recommendations for a resident with dementia and protein-calorie malnutrition, leading to significant weight loss. Despite observations of poor food intake and recommendations from the dietitian, the necessary dietary changes were not implemented, and the physician was not informed.
The facility failed to date and time enteral tube feedings for two residents, leading to potential complications and risk of infections. Observations revealed unlabeled feeding and flush bags, and staff confirmed the lack of labeling, which could result in bacterial growth and infection. The facility's policy required labeling, but no recent training had been provided to staff.
A facility failed to identify and manage the pain of a resident with dementia and a left humerus fracture. The resident, who had moderately impaired cognitive skills, was observed yelling and waving her hands in bed. Despite complaints of pain during transfers and showers, no pain medications were administered recently. The MDS nurse was unaware of the pain complaints, and no pain assessments were found. The DON confirmed that the resident's pain and pain triggers were not identified, contrary to the facility's pain management policy.
The facility failed to ensure a physician managed a resident's care, leading to unaddressed significant weight loss despite recommendations from the RD. The physician was unaware of the resident's weight loss and dietary needs due to poor communication.
The facility failed to ensure staff competency in managing diabetes, leading to a critical low blood sugar episode for a resident who was subsequently hospitalized. Interviews revealed that staff had not received diabetes management training while employed at the facility, relying solely on their nursing school education. The Director of Nursing confirmed that the last annual skills check was conducted in September 2022, and that competency training should be completed upon hire and annually.
The facility failed to post daily nurse staffing information for five consecutive days due to the absence of the DSD, who expected team leaders to handle the posting. Both the DSD and DON acknowledged the importance of this requirement, which is mandated by the facility's policy.
The facility failed to properly label and store medications in three instances: an unsecured medication cup at a nurse's station, an undated Breztri Aerosphere inhaler in a medication cart, and a lack of temperature monitoring for the Automated Drug Dispensing System (ADDS).
A resident with a documented dislike for milk was consistently served milk with every meal, despite her requests and documented preferences. Interviews with staff confirmed that the resident's preferences were not being honored, leading to feelings of being ignored and disrespected.
The facility failed to store, date, and protect food under sanitary conditions in one of two freezers. A clear plastic bag of dinner rolls and a partially opened bag of parmesan cheese were found without proper sealing and dating. The DSS and RD-C confirmed the deficiency, emphasizing the importance of dating and sealing food items to prevent foodborne illness. The DON expected adherence to safe food practices as per the facility's policy.
The facility failed to ensure proper glove use and hand hygiene by a staff member handling soiled linens. The staff member applied hand sanitizer to her gloves instead of removing them and sanitizing her hands, contrary to training and facility policy. Both the housekeeping supervisor and the assistant director of nursing confirmed this was not acceptable practice.
The facility failed to ensure that resident rooms housed no more than four residents, with some rooms accommodating up to six residents. Despite this, no quality of care or quality of life concerns were observed. A continuance of a previously granted waiver allowing more than four residents per room was recommended.
The facility failed to ensure that a multiple resident room met the minimum space requirement of 80 square feet per resident. Room [ROOM NUMBER] measured 479 square feet and housed six residents, resulting in 79.83 square feet per resident. Despite no complaints or observed quality concerns, the room did not meet regulatory standards. A continuance of the waiver was recommended.
Failure to Follow Post-Fall Protocols Resulting in Delayed Diagnosis of Injuries
Penalty
Summary
The facility failed to provide necessary care and services according to its fall policies and procedures for a resident who experienced an unwitnessed fall. The resident, who had a history of Parkinson's disease, moderate cognitive deficits, and required maximum assistance with transfers, was left unattended on the toilet and subsequently fell into the bathtub. After the fall, the resident experienced rib pain and was found by staff in the bathtub, but immediate post-fall assessments, including neurological checks, were not performed as required by facility policy. Interviews and record reviews revealed that staff did not initiate post-fall neuro-checks or notify the resident's physician and responsible party immediately after the incident. Instead, these actions were delayed until the following day, despite the resident exhibiting pain and bruising in the rib area. The facility's fall management policy required neurological checks for 72 hours following an unwitnessed fall or suspected head injury, as well as prompt notification of the physician and responsible party, but these procedures were not followed. The delay in post-fall care and assessment resulted in a delayed diagnosis of multiple rib fractures for the resident. Staff interviews indicated confusion or misinformation regarding post-fall protocols, with one nurse stating that the previous DON had advised that post-fall procedures were not necessary in such cases. The current DON confirmed that the expected protocol was not followed, which contributed to the delay in identifying and treating the resident's injuries.
Failure to Provide Adequate Supervision Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of Parkinson's disease, moderate cognitive deficits, and lower extremity impairments was admitted to the facility and assessed as high risk for falls. The resident required maximum assistance with toilet transfers. On the day of the incident, the resident was assisted to the toilet by nursing staff and then left alone for privacy at the resident's request. While unattended, the resident lost balance and fell into the bathtub, sustaining multiple rib fractures and experiencing pain. The fall was unwitnessed, and the resident waited approximately five minutes before staff responded to her calls for help. Interviews with staff confirmed that the resident was left unattended in the bathroom despite her need for significant assistance with transfers and her high fall risk status. The facility's own investigation and care plan documentation indicated that the resident should not have been left alone due to her impairments and risk factors. The facility's fall management policy required providing a safe environment and supervision to prevent accidents, which was not followed in this instance, resulting in harm to the resident.
Failure to Discard Expired Bread
Penalty
Summary
The facility failed to store foods under sanitary conditions when eight loaves of bread with use by labels were not discarded. During a kitchen tour with the Dietary Supervisor (DS), eight loaves of bread were observed with a use by date of 1/6/25, which had not been discarded. The DS acknowledged that the bread should have been discarded either a day before or on the use by date. The Registered Dietitian (RD) confirmed that bread with use by labels should be thrown away on or before the use by date. This oversight had the potential to cause food contamination and spread food-borne illness among the 72 residents of the facility.
Violation of Resident Privacy Due to Unattended Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, resulting in a violation of privacy for Resident 28. The resident, who was re-admitted to the facility with diagnoses including Acute Prostatitis, a local skin infection, and a urinary tract infection, had their vital signs record left unattended on the counter of nursing station one. This record contained sensitive information such as the resident's name, room number, and various vital signs, making it accessible to anyone passing by. Interviews with the Infection Preventionist/Registered Nurse (IP/RN) and the Director of Nursing (DON) confirmed that the vital signs record is considered part of the medical records and should be kept secure and confidential. Both acknowledged that leaving the record unattended violated the resident's right to privacy. The facility's policy on the disclosure of protected health information (PHI) mandates that medical records be kept secure and shielded from public view, which was not adhered to in this instance.
Failure to Provide Communication Tools for Residents with Communication Difficulties
Penalty
Summary
The facility failed to provide necessary communication tools for two residents, Resident 13 and Resident 36, who had documented communication difficulties. Resident 13, diagnosed with dementia, hemiplegia, and urinary retention, was observed struggling to communicate using incomprehensible words, sign language, and head nods. Despite the care plan indicating the need for alternative communication tools due to communication problems related to dementia and a cerebrovascular accident, Resident 13 was not provided with any such tools. This was confirmed by both a licensed nurse and the Director of Nursing, who acknowledged the absence of a communication tool for Resident 13. Similarly, Resident 36, diagnosed with aphasia and hemiplegia, was observed having difficulty communicating and using sign language and gestures. The care plan for Resident 36 also specified the need for alternative communication tools due to expressive and receptive aphasia. However, like Resident 13, Resident 36 was not provided with any communication tools. This deficiency was acknowledged by the same licensed nurse and the Director of Nursing, who confirmed the necessity of a communication tool for Resident 36 to convey their needs effectively.
Failure to Document and Monitor Skin Discoloration
Penalty
Summary
The facility failed to provide necessary care for a resident, identified as Resident 54, by not assessing and documenting skin discoloration as required. Resident 54, who was admitted with diagnoses including dementia and atrial fibrillation, was observed to have a purplish discoloration on the right side of the right elbow during an initial tour. Despite the presence of this discoloration, there was no documentation on the resident's treatment activity record (TAR) to monitor the condition, as confirmed by the Director of Staff Development (DSD). The Director of Nursing (DON) stated that it was expected for nursing staff to monitor and document any skin changes on the residents' TAR. However, this expectation was not met in the case of Resident 54, as the skin discoloration was neither documented nor monitored. The facility's policy on Skin and Wound Management required new non-pressure ulcers, bruises, and lacerations to be documented on the 24 Hour Log and an incident report to be completed by a Licensed Nurse, which was not adhered to in this instance.
Failure to Ensure Gastric Tube Free from Air Bubbles
Penalty
Summary
The facility failed to ensure that a gastric tube (GT) was free from potential complications for a resident with dysphagia, cerebral infarction, and hemiplegia. During an observation and interview with the Director of Staff Development (DSD), it was noted that the resident's GT had an air bubble in the line, which could lead to abdominal discomfort. The DSD acknowledged that the licensed nurse responsible for preparing the GT should have primed the tube to prevent air from entering. Additionally, the resident and their GT should have been checked every two hours to ensure the feeding was free from air. The Director of Nursing (DON) confirmed that licensed nurses are expected to check residents' GTs before, during, and after the infusion of GT feeding to ensure they are free from air bubbles. The facility's policy on enteral feedings, dated September 7, 2023, also indicated that pump tubing should be primed. The failure to adhere to these protocols resulted in a deficiency, as the presence of air in the GT line had the potential to compromise the resident's health condition.
Failure to Timely Replace Oxygen Cylinder for Resident
Penalty
Summary
The facility failed to replace an oxygen cylinder for Resident 61 in a timely manner, which had the potential to affect her wellbeing. Resident 61 was admitted with diagnoses including heart failure and respiratory failure with hypoxia, requiring continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. During an observation and interview, Resident 61 reported that no oxygen was coming out of her cannula, and her oxygen tank was found to be empty. Certified Nursing Assistant (CNA) 6 confirmed the tank was empty and needed replacement. The Director of Staff Development stated that Resident 61's oxygen tank should have been checked every two hours for fullness and functionality. The Director of Nursing expected the nursing staff to provide adequate oxygenation and stated that the oxygen tank should have been replaced timely to prevent shortness of breath. The facility's policy on oxygen therapy, dated November 2017, indicated that oxygen should be administered per physician orders. However, the failure to replace the oxygen tank as required led to a deficiency in providing safe and appropriate respiratory care for Resident 61.
Deficiency in Staff Competency and Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure that licensed nurses followed physician orders and had adequate competency in providing care to residents using low air loss mattresses and wound vacuum therapy. Observations and interviews revealed that the licensed nurse (LN) was unaware of the manufacturer's guidelines for setting low air loss mattresses according to residents' weights. This lack of knowledge was evident in the care of four residents who were observed with incorrect mattress settings. The Director of Nursing (DON) admitted to not being aware of the different types of low air loss mattresses and pumps used in the facility and acknowledged the absence of staff training and competency in this area. Additionally, the facility did not ensure that physician orders for wound vacuum therapy were clear and complete. Two residents were receiving wound vacuum therapy with a negative pressure setting of 125 mm/Hg, despite the physician orders being incomplete and lacking specific pressure settings. The LN admitted that the orders should have been clarified with the physician but were not. The DON confirmed that the orders were incomplete and should have been clarified to ensure they were carried out correctly for patient safety. The facility's policies and procedures were not followed, as evidenced by the lack of adherence to the manufacturer's guidelines for low air loss mattresses and the failure to confirm that physician orders were clear, complete, and accurate. This deficiency in staff competency and adherence to procedures posed a potential risk to the residents' care and well-being.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a registered nurse (RN) for at least eight hours a day, affecting 99 residents. This deficiency was identified through a review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) for the fourth quarter of 2024, which showed no RN hours on four or more days. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that there was no RN coverage for at least eight hours a day on specific dates in July, August, and September 2024. The Director of Nursing (DON) also acknowledged that an RN should have been present in the facility for at least eight hours per day to provide necessary and appropriate care. The facility's policy requires at least one RN or Licensed Vocational Nurse to be present at all times, in addition to the Director of Nursing Services (DONS).
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, which posed a potential risk to their well-being. Resident 2, diagnosed with hemiplegia, diabetes, and a pressure ulcer, had specific physician orders for Humalog (Insulin Lispro) to be administered subcutaneously before meals and at bedtime, based on a sliding scale for blood sugar levels. However, the Medication Administration Record (MAR) indicated that the blood sugar checks and insulin administration were not conducted before scheduled meals and were not within one hour of the scheduled medication administration times on multiple occasions. Licensed Nurse 1 confirmed that the insulin was administered after meals, contrary to the physician's orders, and the Director of Nursing acknowledged the importance of timely insulin administration to prevent adverse health effects. Similarly, Resident 65, also diagnosed with hemiplegia and diabetes, had physician orders for Humalog to be administered before meals and at bedtime. The MAR showed that the insulin administration did not occur before scheduled meals and was not within the prescribed time frame on several dates. Licensed Nurse 1 and the Director of Nursing both confirmed that the physician's orders were not followed, and the insulin was administered after meals. The facility's policy and procedure for medication administration, last revised in 2012, stated that medications should be administered as directed by a licensed nurse and upon the order of a physician, which was not adhered to in these cases.
Medication Error Rate Exceeds 5% Due to Identification Failures
Penalty
Summary
The facility failed to ensure that the medication error rate during medication pass did not exceed 5 percent, resulting in an error rate of 16 percent. This was identified through observations, interviews, and record reviews. During a medication pass, a Licensed Nurse (LN) administered medications to a resident without verifying the resident's identity using two identifiers, as required by the facility's policy. The resident had a medical history that included diabetes, peripheral vascular disease, and a foot ulcer. The LN admitted to not checking the resident's identifiers, despite being familiar with the resident, and acknowledged the importance of following the identification process to ensure resident safety. Another incident involved a different resident with diagnoses including dementia, hemiplegia, and urinary retention. During a medication pass, another LN administered medication without using two identifiers to verify the resident's identity. The LN stated that she identified the resident by name and was familiar with him, but recognized the need to adhere to the policy to prevent medication errors. The Director of Nursing confirmed the importance of following the identification process to prevent errors and ensure resident safety. The facility's policy, last revised in 2012, mandates that medications must be given by the LN who prepared them and that the resident's identity must be verified before administration.
Infection Control Lapses in Water Management and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control procedures, as evidenced by two significant observations. First, a 550-gallon water reservoir tank located outside the kitchen was found to be leaking and had a greenish-black substance, identified as mold, surrounding the opening of the faucet. The faucet was not covered, and the water inside the tank was deemed unusable. Interviews with the Infection Preventionist (IP), Maintenance Supervisor (MS), and Director of Nursing (DON) revealed that regular inspections of the water reservoir tank were not conducted, which led to the presence of mold and potential waterborne pathogens. Additionally, the facility failed to ensure proper urinary catheter care for a resident with dementia, hemiplegia, and urinary retention. The resident's urinary catheter bag was observed touching the floor while attached to their wheelchair. The DON acknowledged that the catheter bag should not touch the floor to prevent contamination and infection spread. The facility's policy on catheter care, which mandates that the catheter and collecting bag be anchored to avoid floor contact, was not adhered to in this instance.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulatory requirement that resident rooms house no more than four residents. During the annual recertification survey, it was observed that two rooms had the potential to accommodate five residents each, and seven rooms could accommodate six residents each. This configuration was contrary to the standards set forth in 42 CFR section 483.70(d)(1)(i). Despite these observations, there were no noted quality of care or quality of life concerns directly related to the number of residents in the rooms. The facility had previously been granted a waiver by CMS, allowing more than four residents per room, and a continuance of this waiver was recommended, contingent upon timely renewal by CMS.
Room Size Deficiency in Multiple Resident Room
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum space of 80 square feet per resident in a multiple resident room. During the annual recertification survey, it was observed that room [ROOM NUMBER] measured 479 square feet and was intended to house six residents, resulting in an allocation of only 79.83 square feet per resident. Despite this deficiency, the five residents occupying the room did not express any complaints, and there were no observed concerns regarding their quality of care or quality of life. The facility had previously been granted a waiver from the Centers for Medicare and Medicaid Services (CMS) allowing for less than 80 square feet per resident, and a continuance of this waiver was recommended.
Inadequate Assistance During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance during a transfer for a resident with a left above-the-knee amputation, resulting in a skin tear. The incident occurred when a Restorative Nursing Assistant (RNA) transferred the resident from bed to a Hoyer lift alone, contrary to the facility's policy requiring two-person assistance for such transfers. The resident, who was dependent on substantial maximum assistance for transfers due to limited physical mobility, experienced discomfort during the transfer, which was later associated with a skin tear on the amputated leg. Interviews with the RNA, Treatment Nurse (TXN), and Director of Nursing (DON) confirmed the facility's policy of requiring two-person assistance for mechanical lift transfers to ensure safety and prevent accidents. The resident's care plan and physician orders also indicated the need for two-person assistance due to partial weight-bearing status and dependency on others for mobility. The incident was reported to the department, and the resident's cognition was noted to be intact, as indicated by a BIMS score of 14 on the Minimum Data Set (MDS).
Failure to Revise Care Plan for Inappropriate Resident Behavior
Penalty
Summary
The facility failed to revise the care plan for a resident who exhibited inappropriate behavior towards female residents. The resident, diagnosed with dementia, was admitted to the facility and had a history of touching female residents on their arms or thighs, which was perceived as inappropriate by some. Despite these behaviors being documented in progress notes, the care plan was not updated to reflect these incidents or to provide guidance for staff on how to manage the behavior. Interviews with facility staff, including a CNA and an LN, revealed that the resident's behavior was known, and staff attempted to redirect him, although he sometimes became aggressive. The Director of Nursing confirmed that there was no care plan addressing the resident's behavior, which was necessary to alert staff and implement appropriate interventions. The facility's policy required care plans to be reviewed and revised to address changes in behavior, but this was not done in this case.
Failure to Monitor and Communicate Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with diabetes, leading to severe hypoglycemia and hospitalization. Resident 51, who had severe cognitive impairment, was on multiple diabetic medications, including Glimepiride, Insulin glargine, Sitagliptin, and Pioglitazone. Despite the resident's history of low blood sugar, the facility did not monitor blood sugar levels according to standard practice, nor did they notify the resident's physician of hypoglycemic episodes. This lack of monitoring and communication resulted in the resident becoming unresponsive and being sent to the hospital, where they were diagnosed with sulfonylurea-induced hypoglycemia and a urinary tract infection. Interviews with the facility's licensed nurses, medical doctor, and pharmacy consultant revealed that Resident 51's blood sugar should have been checked at least twice daily due to the multiple diabetic medications. However, the Medication Administration Record (MAR) and progress notes showed several instances where blood sugar levels were dangerously low, and there was no documented evidence that the physician was notified or that the blood sugar was reassessed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed these findings and acknowledged that the facility's hypoglycemia protocol was not followed. The facility's policy on hypoglycemia required immediate notification of the attending physician and close monitoring of the resident's condition, including checking blood sugar and vitals every 15 minutes until stable. However, this protocol was not adhered to, as evidenced by the lack of documentation and communication regarding Resident 51's low blood sugar episodes. The failure to follow these procedures contributed to the resident's severe hypoglycemia and subsequent hospitalization.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer for a resident, identified as Resident 35, who was admitted with a history of hemiplegia, hemiparesis, cerebral infarction, and diabetes mellitus. Despite being at high risk for pressure ulcers and dependent on staff for bed mobility, there was no care plan developed for Resident 35's stage II pressure ulcer identified on 9/17/23. Over time, the ulcer deteriorated to a stage III pressure ulcer by 11/7/23, as documented in the resident's progress notes and change of condition assessments. Observations revealed that Resident 35 was frequently found lying upright in bed directly on her sacrum, even though a wedge pillow was available but not used. The resident was observed in this position multiple times over several days, indicating a lack of proper repositioning. Interviews with CNA 23 and LN 31 confirmed that there was no documentation or evidence that Resident 35 was turned and repositioned as required to prevent further decline of the pressure ulcer. The Director of Nursing acknowledged the lack of documentation and the failure to turn and reposition Resident 35 frequently, which contributed to the deterioration of the pressure ulcer from stage II to stage III. The facility's policy on pressure injury prevention and the lesson plan on pressure injury management both emphasized the importance of repositioning residents at least every two hours, which was not adhered to in this case.
Failure to Provide Haircuts for Residents
Penalty
Summary
The facility failed to provide haircuts for residents, including Resident 42, over a 10-month period from April 1, 2023, to February 14, 2024. Resident 42, who has dementia and requires assistance with personal hygiene, was observed with long, unkempt hair. Interviews with Resident 42's daughter and the resident himself confirmed that he preferred to keep his hair short. The Activity Director (AD) acknowledged the lack of haircut services since the facility's change of ownership in April 2023, citing delays in the hospital's vetting process for a new barber or beautician. Family members had been bringing in their own hairdressers for some residents, but those without family support had not received haircuts. The AD expressed frustration with the delay and its impact on residents' dignity and self-esteem. The Director of Nursing (DON) confirmed the issue, stating that no haircuts had been performed for a long time and acknowledging the potential negative impact on residents' self-esteem and dignity. The facility's policies on Resident Rights-Quality of Life and Resident Rights-Accommodation of Needs emphasize the importance of grooming and accommodating individual preferences, but no specific policies related to haircuts or ADLs were found. The deficiency highlights a failure to maintain residents' quality of life and dignity by not providing necessary grooming services.
Failure to Develop Effective QAPI Program
Penalty
Summary
The facility failed to develop an effective Quality Assurance Performance Improvement (QAPI) program, as the committee did not consistently track, address, and follow up on quality issues affecting the residents. Specific deficiencies included a non-functional call light system for several days, failure to offer Covid immunizations to residents, worsening of a pressure ulcer for a resident, lack of haircuts for residents over a 10-month period, unidentified hypoglycemia in a diabetic resident leading to a 10-day hospitalization, and failure to routinely perform Gradual Dose Reductions (GDRs) for residents on antipsychotic medications. Additionally, the Medical Director did not provide oversight regarding GDRs. These failures placed all residents at risk for accidents, infections, and worsening physical and psychosocial harm. During an interview, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) acknowledged that the last QAPI meeting had been held several months prior, and although problems were identified, no formal Quality Assurance (QA) meetings were conducted to address these issues. The malfunctioning call light system was known but not reported to the California Department of Public Health (CDPH) or addressed with a safety watch. Infection control practices were reviewed, but the lack of Covid vaccines was not discussed. Pressure ulcers were part of the QAPI discussion, but no significant improvement was noted. The issue of haircuts was not escalated to the necessary level for resolution. Diabetes management and staff training were not adequately discussed, and no plan was developed for GDRs. The previous administrator had not developed a plan for these issues, and more QAPI interventions were deemed necessary by the current administration to identify and solve these problems.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by several deficiencies that were not adequately tracked, addressed, or followed up on. The call light system was non-functional for several days, and the facility did not implement a safety watch or report the issue to the California Department of Public Health (CDPH). Infection control practices were also lacking, as COVID-19 immunizations were not offered to residents. Additionally, a resident's pressure ulcer worsened, and haircuts were not provided to residents for an 11-month period due to a lack of a necessary contract. A resident with diabetes experienced unidentified hypoglycemia for two days, resulting in a 10-day hospitalization. Furthermore, Gradual Dose Reductions (GDRs) for residents on antipsychotic medications were not routinely performed, and the Medical Director did not provide oversight for identifying problem-prone QAPI interventions. The facility's QAPI committee had not met formally since October 10, 2023, and although problems were identified, no Performance Improvement Plans were developed. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) acknowledged these issues during an interview. The DON and ADON were unaware of the lack of COVID-19 vaccines being offered, and the RC noted that pressure ulcers were discussed but not adequately addressed. The Administrator admitted that the issue of haircuts was not escalated to the necessary level for resolution, and diabetes management and staff training were not included in QAPI discussions. The previous administrator had identified GDRs as an issue but did not develop a plan to address it. Overall, the facility's failure to implement an effective QAPI program placed all residents at risk for accidents, infections, and worsening physical and psychosocial harm.
QAPI Committee Failed to Meet Quarterly
Penalty
Summary
The facility Quality Assurance Performance Improvement (QAPI) committee failed to meet at least quarterly, as required by their own QAPI plan and policy. During a record review and interview conducted on 2/20/24, it was found that the last QAPI meeting was held on 10/10/23. The Administrator admitted that although problems had been identified, the committee had not formally convened to conduct a proper QA meeting. This failure to hold regular QAPI meetings had the potential to affect the safety and quality of care provided to residents.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, leading to potential risks in their care and health status. Resident 14, who was admitted with End Stage Renal Disease and required dialysis, did not have a care plan addressing his dialysis needs. Interviews with LN 31, LN 35, and the DON confirmed the absence of a dialysis care plan, which was crucial for guiding healthcare staff in providing appropriate care for Resident 14's condition. This oversight was observed during multiple interviews and record reviews, highlighting a significant gap in the resident's care management. Resident 51, diagnosed with Diabetes Mellitus, had a care plan that lacked resident-specific interventions for monitoring abnormal blood sugar levels. Interviews with LN 31 and the ADON revealed that the care plan was not individualized to address the resident's specific needs. Additionally, Resident 7, who had dementia and a left humerus fracture, did not have a care plan for pain management despite frequent complaints of pain during transfers and other activities. Interviews with CNA 22, LN 22, and MDSN 1, along with observations, confirmed the absence of a pain care plan, which was necessary to address the resident's pain triggers and ensure comfort. The DON acknowledged the need for a comprehensive, person-centered care plan to manage Resident 7's pain effectively.
Failure to Evaluate Fall Risks and Conduct Smoking Assessments
Penalty
Summary
The facility failed to consistently evaluate Fall Risk Assessments and conduct Care Conferences after each resident fall, which led to multiple falls for two residents. Resident 19, who had severe dementia, experienced several falls without proper post-fall evaluations or new interventions being implemented. Despite being at high risk for falls, the resident's fall risk score was inconsistently documented, and no new measures were taken to prevent future falls after each incident. Similarly, Resident 49, who had hemiplegia following a stroke, experienced numerous falls without appropriate post-fall evaluations or care conferences. The resident's fall risk score was often lowered instead of increased, and no new interventions were added to the care plan to prevent future falls. The facility's staff, including CNAs and LNs, were aware of the procedures but failed to follow them consistently, leading to repeated falls and inadequate preventive measures. Additionally, the facility did not complete continuous quarterly safety smoking evaluations for five residents who smoked. These residents had various conditions that impaired their ability to smoke safely, yet no follow-up evaluations were conducted to reassess their smoking safety. The facility's policy required quarterly assessments, but this was not adhered to, posing a risk for smoking-related injuries.
Failure to Document Non-Pharmaceutical Interventions and Gradual Dose Reductions
Penalty
Summary
The facility failed to document non-pharmaceutical interventions or gradual dose reductions (GDR) for three residents reviewed for unnecessary medication review. Resident 3, who was readmitted with diagnoses including dementia and schizoaffective disorder, had no documented evidence that the physician agreed or disagreed with the consulting pharmacist's recommendation for a GDR. Additionally, no non-pharmaceutical interventions were attempted or documented for Resident 3, and an injection of Ativan was administered without prior documentation of behavior or non-pharmaceutical interventions. Resident 42, who was readmitted with dementia and behavior disturbances, also had no documented evidence that the physician agreed or disagreed with the consulting pharmacist's recommendation for a GDR. The facility had not conducted psychotropic medication care conferences since merging with a hospital, leading to a lack of evaluation of the necessity of the medications and potential dose reductions. Interviews with staff confirmed that non-pharmaceutical interventions were not attempted or documented for Resident 42. Resident 10, who was admitted with a history of depression, had a recommendation from a psychiatrist to decrease the dosage of Sertraline, but there was no evidence that this recommendation was followed. The Director of Nursing confirmed that the missed psychotropic meetings led to a failure to monitor behaviors and follow up on medication regimen reviews. The facility's policy on behavior and psychotropic drug management was not adhered to, resulting in a break in the system for evaluating the necessity of psychotropic medications.
Governing Body Fails to Ensure Effective Oversight and Resources for Resident Care
Penalty
Summary
The facility's Governing Body failed to ensure effective oversight and necessary resources for resident care services, which had the potential to affect the quality of care provided to residents. During a record review, it was found that the Governing Body did not adequately review or discuss critical aspects of resident care, such as pressure ulcers, falls with significant injury, equipment malfunctions, and performance improvement projects (PIPs). The facility's policies indicated that the Governing Body should be involved in these areas, but there was no evidence of effective implementation or oversight. An interview with the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Consultant (RC) revealed that the Governing Body met monthly, but communication and coordination among the facility's leadership were still developing. The facility's policies and procedures, including the Organization Performance Improvement Plan, emphasized the importance of the Governing Body's role in quality oversight and regulatory compliance. However, the lack of effective oversight and resource allocation by the Governing Body was evident, as they failed to ensure the highest practical physical, mental, and psychosocial well-being of each resident.
Failure to Oversee Psychotropic Drug Use and Gradual Dose Reductions
Penalty
Summary
The facility's Medical Director (MD 1) failed to oversee care area concerns related to psychotropic drug use and Gradual Dose Reductions (GDR) for 38 out of 83 residents currently receiving psychotropic medications. As a result, these residents did not have their psychotropic medications evaluated monthly, and their care needs were not addressed in a timely manner. There were no psychotropic care conferences, and no GDRs were attempted for nine months. This lapse in oversight could potentially be harmful to residents, as the medications have side effects that need regular monitoring and adjustment. During an interview, MD 1 admitted that the management team, which he led, was expected to meet monthly to evaluate nonpharmacological interventions, determine the amount of behaviors exhibited, and assess the number of side effects displayed. However, MD 1 acknowledged that the facility had fallen behind in conducting these reviews and GDRs. The facility's Medical Directorship Agreement and the Medical Director Duties outlined the responsibilities of the MD, including the supervision and oversight of health services and the review of residents' conditions and medication regimens. Despite these outlined duties, the MD admitted that since the facility changed ownership, psychotropic medications were not a primary focus, leading to the deficiency.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, re-offer, or administer COVID-19 vaccinations to a total of 39 residents, including five sampled residents and 34 newly admitted residents after the facility reopened. This failure was identified through interviews and record reviews, which revealed that the facility had not conducted a COVID-19 vaccination clinic since March 2023. The facility's vaccination tracking log inaccurately documented refusals for residents who were never offered the vaccine. Resident 56, for example, stated he had not been offered the vaccine upon admission or during his stay and expressed a desire to receive it. The facility's Infection Control Surveillance indicated that 50 residents tested positive for COVID-19 in January 2024, including 20 newly admitted residents. Interviews with the ADON, IPN 22, IPN 23, and the DON confirmed that the facility had not offered COVID-19 vaccinations to residents upon readmission or new admission since reopening in September 2023. The facility's policy required that residents be evaluated for vaccination status upon admission and offered the vaccine within seven days if not previously vaccinated. The DON acknowledged that the facility should have offered vaccinations to both readmitted and newly admitted residents. The failure to follow the facility's COVID-19 Vaccination Program policy potentially placed residents, staff, and visitors at risk for COVID-19 infection.
Failure to Recognize and Honor Resident's Advanced Directive
Penalty
Summary
The facility was unaware of an Advanced Directive related to a resident's wishes for resuscitative efforts. Resident 36, who was admitted with Parkinson's disease, had an Advanced Directive indicating 'Do not resuscitate, no life supporting measures' that was scanned into the electronic record. However, the physician's order listed CPR, and there was no documented evidence of a POLST in the clinical record. During a multidisciplinary care conference, the section for resuscitative wishes was left blank and unmarked. Interviews with the resident and staff revealed that the resident had expressed her wishes to not have CPR performed, but these wishes were not communicated or documented properly within the facility. The ADON was unaware of the Advanced Directive in the electronic chart and acknowledged the potential for the resident's wishes to not be followed. The DON stated that all resident wishes for Advanced Directives and POLST should be recognized and honored. The facility's policies on Advanced Directives and POLST were not adhered to, leading to the deficiency.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, homelike environment in two specific instances. First, an exterior resident room door for one of 25 rooms had peeling paint. This room housed four residents, two of whom were cognitively impaired. The Director of Maintenance (DM) was unaware of the issue as he did not keep a maintenance log and only addressed repairs as they were reported. The Administrator (ADM) acknowledged that the peeling paint could be ingested by confused residents and agreed that the door needed repair. Second, the exterior shower room door frame in Station B had multiple holes, exposed drywall, and two protruding nails. The DM stated that an outside company had installed new shower door frames but had not returned to complete the wall repairs. The DM had not followed up with the company and admitted that the exposed nails could pose a risk of injury. The ADM also confirmed that the condition of the shower wall did not present a homelike environment and could potentially injure residents and staff.
Failure to Capture Accurate MDS Information
Penalty
Summary
The facility failed to capture and transmit accurate MDS information to CMS for two residents, which had the potential to affect the care and services provided to them. Resident 3 was readmitted with diagnoses including dementia and schizoaffective disorder. However, the Admission MDS did not identify the diagnosis of schizophrenia, despite it being listed in the Admission Record. The MDSN acknowledged the oversight and stated that CMS did not have the correct information on Resident 3's current health status due to this error. Resident 36 was admitted with a diagnosis of Parkinson's disease and had conflicting information regarding resuscitative wishes. The physician's order indicated CPR, while the Advanced Directive scanned into the electronic record indicated Do Not Resuscitate. The quarterly MDS did not capture any choices for life-sustaining treatment, leaving all sections blank. The MDSN admitted that the POLST and Advanced Directive were not captured, resulting in CMS and the facility being unaware of the resident's resuscitative wishes. The DON emphasized the importance of accurate assessments for all residents to ensure the facility and CMS are aware of their resuscitative preferences.
Failure to Complete PASARR Level 2 for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review Level 2 (PASARR) was completed after a new diagnosis of schizophrenia was made for a resident. The resident was readmitted to the facility with diagnoses including dementia and schizoaffective disorder. However, the Admission MDS did not include the diagnosis of schizophrenia, and the original PASARR Level 1 was completed as negative. The MDS nurse admitted to missing the schizophrenia diagnosis, which should have triggered a new PASARR Level 1 and potentially a Level 2 assessment by the state to ensure appropriate placement and services for the resident. The Director of Nursing confirmed that MDS assessments need to be accurate on admission to ensure residents receive the necessary care and services. The facility's policy mandates a new PASARR Level 1 screening for residents experiencing a significant change in condition, and if indicated, a Level 2 screening should be completed by the state. The facility could not provide documented proof that a PASARR Level 2 was completed or that they followed up with the state to ensure its completion.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise individualized care plans for two residents, which had the potential to impact their health status and prevent further decline. Resident 19, who was admitted with dementia and had a history of falls, was observed with bolsters on his mattress to prevent falls. However, the care plan did not include the use of these bolsters. The ADON confirmed that the care plan should have been updated to include the bolsters to ensure staff were aware of the fall prevention measures in place for Resident 19. Resident 21, also admitted with dementia and protein-calorie malnutrition, was observed consuming less than half of his meals during multiple observations. The care plan for weight loss, initiated earlier, referenced a nutrition progress note rather than documenting specific interventions. The RD and ADON both acknowledged that the care plan should have included specific nutrition interventions to address Resident 21's weight loss. The lack of an updated care plan could result in further weight loss, as it failed to communicate the necessary interdisciplinary interventions for the resident's nutrition needs.
Failure to Follow Up on Dietary Recommendations for Resident
Penalty
Summary
The facility failed to follow up on a recommendation for diet changes related to weight loss for Resident 21, who was admitted with diagnoses including dementia and protein-calorie malnutrition. Observations showed that Resident 21 consumed less than half of the food provided during meals and refused nutritional supplements. The Minimum Data Set indicated significant weight loss, and the resident was on a carbohydrate-controlled diet with nutritional supplements prescribed three times daily. Despite recommendations from the dietitian to liberalize the diet and reduce supplements, these changes were not implemented, and the physician was not informed of the resident's weight loss or dietary needs. Interviews with the dietitian, Assistant Director of Nursing (ADON), and the physician revealed a lack of communication and follow-through on the recommended dietary changes. The dietitian was unaware of the previous recommendations, and the ADON could not explain why the recommendations were not acted upon. The physician confirmed that he had not been contacted about the resident's weight loss or dietary recommendations and had not ordered any recent labs to assess nutritional status. The facility's policy on nutritional status evaluation was not followed, leading to a failure to address the resident's significant weight loss and nutritional needs.
Failure to Label Enteral Tube Feedings
Penalty
Summary
The facility failed to date and time enteral tube feedings for two residents, leading to potential complications and risk of infections. Resident 49, who was admitted with hemiplegia and moderate protein-calorie malnutrition, was observed with an enteral pump and feeding bags that were not labeled with the date and time. The Licensed Nurse (LN) confirmed that the bags were not labeled, which could lead to bacterial growth and infection. The Assistant Director of Nursing (ADON) emphasized the importance of labeling to prevent bacteria growth and ensure safety. Resident 81, who was readmitted with a stroke, dysphagia, and moderate protein-calorie malnutrition, was also observed with unlabeled tube feeding and water flush bags. The LN stated that the previous nurse had not written the start time and date, making it impossible to confirm if the resident received the nutrition as ordered. The Director of Nursing (DON) reiterated the expectation that all nurses should label the start and end times for tube feedings to prevent infection and ensure proper nutrition. The facility's policy on enteral feeding required labeling the formula container and tubing with the date and time. However, the Director of Staff Development (DSD) could not locate any documentation of tube feeding training or in-services provided to the LNs in the past two years. This lack of training contributed to the failure to follow the facility's policy, leading to the observed deficiencies.
Failure to Identify and Manage Resident's Pain
Penalty
Summary
The facility failed to identify and manage the source of pain for a resident with a history of dementia and a left humerus fracture. The resident, who had moderately impaired cognitive skills, was observed yelling and waving her hands in bed. A CNA indicated that the resident yelled when she wanted something, such as being repositioned for comfort. An LN confirmed that the resident complained of pain during transfers and showers but had not been administered any pain medications recently, despite having an order for Tylenol as needed. The LN suggested that pre-medicating the resident before the Restorative Nursing Assistant (RNA) program would be beneficial. Further investigation revealed that the MDS nurse was unaware of the resident's pain complaints during transfers and movement of her extremities. The MDS nurse acknowledged that pain assessments should be conducted on admission, every three months, and when a change in condition is identified, but no pain assessments were found for the resident. The DON confirmed that pain should be evaluated and addressed using indicators such as body language, facial expressions, and mood, but the resident's pain and pain triggers were not identified. The facility's pain management policy indicated that the interdisciplinary team should review and update the care plan for pain management, but this was not done for the resident.
Failure to Manage Resident's Nutritional Care
Penalty
Summary
The facility failed to ensure that the physician supervised and managed the care of a resident (Resident 21) who was admitted with diagnoses including dementia, protein-calorie malnutrition, and diabetes. Observations revealed that Resident 21 consumed less than half of the food provided during meals and refused nutritional supplements. Despite significant weight loss documented by the Registered Dietitian (RD), recommendations to liberalize the diet and reduce supplement fatigue were not implemented. The physician and nurse practitioner did not document any concerns regarding weight loss or poor intake in their progress notes, and the physician was unaware of the RD's recommendations. The facility's policy on nutritional status evaluation was not followed, as the RD's recommendations were not communicated to or acted upon by the physician. Interviews with the RD and Assistant Director of Nursing (ADON) confirmed that the recommended dietary changes were not made, and the physician stated he was not informed about the weight loss or dietary recommendations. This lack of communication and follow-through had the potential to exacerbate Resident 21's weight loss and overall well-being.
Failure to Ensure Staff Competency in Diabetes Management
Penalty
Summary
The facility failed to ensure that staff were competent in managing residents with diabetes, as evidenced by the case of Resident 51. Resident 51, who was admitted with a diagnosis of diabetes, experienced a critical low blood sugar episode and was sent to the hospital. Interviews with multiple licensed nurses (LNs) revealed that they had not received any diabetes management training while employed at the facility, relying solely on their nursing school education. This lack of ongoing training and competency assessment contributed to the failure in managing Resident 51's diabetes effectively, as evidenced by the absence of documented blood sugar checks in the Medication Administration Record (MAR) and the failure to follow the facility's low blood sugar protocol properly. The Director of Nursing (DON) confirmed that the last annual skills check, which included diabetes management, was conducted in September 2022, and that competency training should be completed upon hire and annually thereafter. The facility's policy on staff competency assessment, dated March 17, 2022, mandates that competency assessments be performed upon hire during the employee's 90-day employment period and annually. However, the interviews and record reviews indicated that this policy was not adequately followed, as staff members had not received the necessary training and education on diabetes management while employed at the facility. This deficiency in staff training and competency assessment had the potential to negatively affect Resident 51's health and well-being, as demonstrated by the critical low blood sugar episode that led to hospitalization.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the nurse staffing data was posted and readily accessible to residents and the public, and to accurately document the total number and actual hours worked by the nursing staff. During an initial tour, it was observed that the posted staffing data was outdated by five days. The Director of Staff Development (DSD) admitted that the staff posting had been missed for five consecutive days due to her absence from work, and she had expected team leaders to handle the posting in her absence. The Director of Nursing (DON) also acknowledged the importance of having the staff posting displayed publicly. A review of the facility's policy confirmed that nurse staffing data is required to be posted daily at the beginning of each shift.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to label and store medications properly in three instances. First, a medication cup with two Tylenol pills was left unsecured and unmonitored at a nurse's station, within reach of residents, staff, and visitors. This was acknowledged by a licensed nurse who admitted the medication was meant for a co-worker. The Director of Nursing (DON) confirmed that medications should not be left unattended due to safety concerns. Second, a Breztri Aerosphere inhaler was found in a medication cart without a date indicating when the foil pouch was opened, contrary to the instructions on the packaging. The licensed nurse admitted that without the date, it was impossible to know if the medication was still effective. The DON reiterated that medications must be stored according to instructions to ensure their efficacy. Third, the Automated Drug Dispensing System (ADDS) was not being monitored for temperature controls. The Assistant Director of Nursing (ADON) and the Pharmacy Consultant (PC) both confirmed that the temperature of the area where the ADDS was located was not being monitored, which is necessary to ensure the safety and efficacy of the medications stored within it. The Director of Maintenance also confirmed that temperatures were not taken in the nurse's station where the ADDS was located.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to follow food preferences during meal service for a resident, leading to feelings of being ignored and disrespected. Resident 73, who was admitted with a diagnosis of malignant neoplasm of the head, neck, and face, had a documented dislike for milk, with milk substitutes being acceptable. Despite this, observations and interviews revealed that Resident 73 was consistently served milk with every meal, which she never drank and found wasteful. The resident expressed frustration and anger over the facility's disregard for her preferences. Interviews with the Dietary Services Supervisor (DSS) and the Registered Dietitian Consultant (RD-C) confirmed that the resident's preferences were not being honored. The RD-C acknowledged speaking with Resident 73 about alternative milk options but had not yet implemented any changes. The DSS and the Director of Nursing (DON) both stated that resident preferences should be respected as a resident's right. The facility's policy on dietary profiles and resident preferences also emphasized the importance of reflecting and updating resident preferences in a timely manner, which was not adhered to in this case.
Failure to Store and Date Food Properly in Freezer
Penalty
Summary
The facility failed to store, date, and protect food under sanitary conditions in one of two freezers (mobile kitchen freezer). During an initial kitchen tour, a clear plastic bag of approximately 10 dinner rolls was found knotted and without a date or label. Additionally, a partially opened bag of parmesan cheese with no visible expiration date was observed on the same shelf. The DSS confirmed that the dinner rolls and parmesan cheese were not sealed and dated as required, which could potentially cause foodborne illness if served to residents. The RD-C emphasized the importance of dating all freezer and refrigerator items when opened to ensure proper discard timelines and to seal food packages to preserve quality and prevent freezer burn. The DON expected kitchen staff to follow safe food practices and store food according to guidelines. The facility's policy, titled Receiving Food and Supplies, dated June 2023, mandates that food and supply items be received and handled in accordance with recommended sanitary practices to prevent foodborne illnesses.
Improper Glove Use and Hand Hygiene by Staff
Penalty
Summary
The facility failed to ensure proper glove use and hand hygiene by Staff 21 while handling soiled linens. During an observation, Staff 21 was seen entering the facility's back entrance wearing a personal protection gown and gloves, pushing a barrel containing soiled linens. Staff 21 stopped at the back entrance and applied hand sanitizer to her gloved hands before continuing to push the linen barrel into the laundry room. In an interview, Staff 21 acknowledged that she should not have used hand sanitizer on her gloves. Both the housekeeping supervisor and the assistant director of nursing confirmed that applying hand sanitizer to gloves was not an acceptable practice and that gloves should be removed and disposed of properly before using hand sanitizer on hands. The director of nursing also stated that it is never acceptable to sanitize gloves. A review of the facility's inservice training documents indicated that Staff 21 had attended multiple training sessions on proper hand hygiene and glove use, which included instructions not to reuse or wash gloves and not to substitute glove use for hand hygiene. The facility's hand hygiene policy, revised in September 2020, emphasized that hand hygiene is the primary means to prevent the spread of infections and that wearing gloves does not replace the need for hand hygiene.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to assure that resident rooms housed no more than four residents, as required by regulations. Observations, interviews, and record reviews conducted during the annual recertification survey revealed that two rooms had the potential to accommodate five residents each, and seven rooms had the potential to accommodate six residents each. Despite these findings, there were no observed quality of care or quality of life concerns related to the number of residents in the rooms. The facility had previously been granted a waiver from the requirements, allowing more than four residents per room, and a continuance of this waiver was recommended.
Room Size Deficiency
Penalty
Summary
The facility failed to assure that resident rooms measured at least 80 square feet per resident in room [ROOM NUMBER]. During the annual recertification survey, it was observed that room [ROOM NUMBER] measured 479 square feet and had the potential to house six residents, resulting in an allocated space of 79.83 square feet per resident. Despite the six residents occupying the room having no complaints and no observed quality of care or quality of life concerns, the room did not meet the minimum space requirement as per Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii). A continuance of the waiver from the requirements was recommended, with the expectation that the facility would obtain a timely renewal of the current waiver granted by CMS.
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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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