Providence Holy Cross Med Ctr D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Mission Hills, California.
- Location
- 11600a Indian Hills Road, Mission Hills, Ca 91345, Mission Hills, California 91345
- CMS Provider Number
- 555074
- Inspections on file
- 25
- Latest survey
- December 14, 2025
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Providence Holy Cross Med Ctr D/p Snf during CMS and state inspections, most recent first.
After a repair to the oxygen gas line, the facility failed to have a certified medical gas verifier test and confirm the safety and purity of the oxygen before returning it to service for 24 residents dependent on mechanical ventilation. Instead, the system was deemed safe by the Facilities Director, who was not certified for this task, and no post-repair quality testing was performed, despite the residents' critical reliance on the oxygen supply.
The facility did not establish or implement standardized protocols for identifying infection signs and symptoms or for applying evidence-based criteria, such as Loeb's minimum criteria, before starting antibiotics. A resident was prescribed levofloxacin for a UTI based only on increased heart rate and fever, which did not meet the required criteria. Staff interviews revealed inconsistent use and documentation of antibiotic stewardship practices, and facility policies lacked clear guidance on these processes.
Two residents receiving subcutaneous insulin and heparin did not have their injection sites rotated as required by professional standards, manufacturer guidelines, and facility policy. Nursing staff repeatedly administered injections in the same anatomical areas, and this practice was confirmed through record review and staff interviews. Both residents were dependent on staff for care and had significant medical conditions, but proper site rotation was not performed.
Three residents receiving enteral feeding experienced deficiencies, including failure to label and change medication syringes daily, not replacing a water flush bag within the recommended 24-hour period, and not ensuring the prescribed amount of tube feeding formula was delivered. Nursing staff confirmed these lapses, and facility policies and manufacturer guidelines for infection control and accurate nutrition delivery were not followed.
Surveyors found that oxygen tubing for two residents was in contact with the floor, a humidification bottle for a resident on oxygen therapy was not labeled or documented as changed per protocol, and a Yankauer suction tool was not dated or replaced as required. Staff confirmed these lapses, and facility policies for infection control and equipment maintenance were not followed.
Two residents received repeated subcutaneous injections of insulin and heparin in the same anatomical sites without proper rotation, contrary to facility policy, standards of practice, and manufacturer guidelines. Nursing staff and documentation confirmed that injection sites were not rotated as required, resulting in significant medication errors for both residents.
Surveyors found that kitchen staff failed to store towels, food items, and personal property according to facility policy, with towels left out in the tray line area, expired and unlabeled food in refrigerators, and personal items stored next to food and utensils. Additionally, refrigerator and freezer temperatures were repeatedly out of range without corrective actions documented, all of which contributed to unsafe food storage and preparation practices.
Staff and medical providers entered the room of a resident with CRPA and MDRA without donning required gowns, despite posted contact isolation instructions and facility policy. The resident was dependent on staff for care and had orders for contact isolation due to infectious bacteria. Facility staff confirmed that policy required gowns for anyone entering the room, regardless of anticipated contact.
A resident with severe cognitive impairment and an indwelling urinary catheter had their catheter drainage bag left uncovered and visible from the hallway. Staff confirmed that the drainage bag should have been covered with a dignity bag, as required by the resident's care plan and facility policy, to protect privacy and dignity.
A resident with severe cognitive impairment and multiple medical conditions had their Seroquel dose increased without obtaining new informed consent, as required by facility policy. Nursing staff confirmed that the last consent on file was for a lower dose, and that consent should be obtained for any dose change of psychotropic medications.
A resident with severe cognitive impairment, non-verbal status, and total dependence for ADLs was found to have their call light out of reach, hanging on an enteral feeding pole. Nursing staff confirmed the oversight, stating the call light should have been placed within reach after care, in accordance with facility policy.
Two residents were placed in physical restraints, including mittens and soft wrist restraints, without the required pre-restraint assessments or documentation of least restrictive alternatives. Staff interviews and record reviews confirmed that facility policy requiring assessment and documentation before restraint use was not followed.
A resident with a suprapubic catheter was found with a urinary drainage bag positioned so that the catheter tubing had a dependent loop, contrary to facility policy and standard infection prevention practices. Staff confirmed that catheter tubing should be free of loops to ensure proper urine flow and reduce infection risk.
A resident with diabetes and respiratory failure was administered insulin lispro without a documented indication in the medication order. While the order for insulin glargine included an appropriate diagnosis, the lispro order did not specify a reason, which was confirmed by nursing staff and found to be inconsistent with facility policy requiring the indication for all medications.
A medication cart inspection found that a resident's vitamin B12 bubble pack had a broken seal and was taped closed after medication was removed, instead of being discarded as required. An RN and the nurse manager confirmed this was not in line with facility policy, which mandates immediate disposal of contaminated medications to prevent errors.
The facility did not have standardized protocols for identifying infection signs and symptoms or for applying evidence-based criteria before starting antibiotics. A resident was given levofloxacin for a UTI without meeting the required clinical criteria, and staff interviews confirmed the absence of a consistent process for reviewing antibiotic use. The facility's policy lacked clear guidance on using tracking tools and national standards for antibiotic initiation.
A resident with respiratory failure and seizure disorders, who was unable to communicate effectively, did not have documentation in the medical record that the pneumococcal vaccine was offered or that education was provided to the family or decision-maker. Although a nurse obtained consent from the family, the discussion and vaccine order were not documented as required by facility policy.
A resident with severe cognitive impairment and a tracheostomy, who had physician orders for bilateral hand mittens and soft wrist restraints to prevent self-injury, was observed using these restraints. However, the MDS assessments on multiple occasions failed to accurately document the use of restraints, with staff acknowledging incorrect coding despite ongoing restraint use and valid orders.
A resident with an indwelling urinary catheter and on blood thinner medication experienced hematuria for several days without the physician being notified. This led to an emergency hospital transfer where the resident was diagnosed with septic shock, a UTI, and pneumonia.
A resident with an indwelling urinary catheter and on blood thinner medication experienced continued hematuria without the physician being notified, leading to emergency hospitalization and diagnoses of septic shock, UTI, and pneumonia. The facility failed to follow its policies on change of condition notification and catheter care.
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not complete an assessment for the risk of entrapment prior to the use of four bed siderails (SR) in the raised position for three residents. Additionally, the facility did not obtain a physician's order or informed consent for the use of these restraints and bed alarms.
The facility failed to develop and implement care plans for the use of bed alarms and side rails for several residents, including those with respiratory failure, quadriplegia, traumatic brain injury, and ischemic stroke. The absence of care plans for these devices and medications was confirmed by staff, violating the facility's policy requiring interdisciplinary care plans within seven days of admission.
The facility failed to provide consistent pressure ulcer care for three residents, leading to missing wound assessments, measurements, pictures, and care plan reviews. The RN responsible was on vacation, and the facility was short-staffed, resulting in the omission of necessary wound care documentation and assessments. The Nurse Manager confirmed the importance of timely assessments and reporting to monitor wound progression and involve the interdisciplinary team when necessary.
The facility failed to properly label enteral feeding bottles and water flush bags for three residents, leading to potential risks of complications. The deficiencies included missing dates, times, and prescribed rates, which were necessary to ensure the correct administration of feedings and water flushes.
The facility failed to ensure the safe and appropriate use of bed side rails for three residents by not conducting risk assessments, not reviewing risks and benefits with representatives, and not obtaining informed consent. Residents were observed with four side rails up without proper documentation or physician's orders, contrary to facility policy and manufacturer's guidelines.
The facility failed to follow proper sanitation and food handling practices, including a Food Service Attendant not wearing a hair restraint, unlabeled and undated open food items, and an open package of cheese without an open date. These deficiencies had the potential to place six out of 43 residents at risk for foodborne illnesses.
The facility failed to implement its antimicrobial stewardship policy for a resident when clindamycin was ordered indefinitely and not monitored for 77 days. The resident had a history of multidrug-resistant infections, and the antibiotic was administered multiple times without a stop date. Staff acknowledged the oversight, which was against the facility's policy to optimize antibiotic therapy and prevent resistance.
The facility failed to honor the residents' right to a dignified existence by not covering a resident's urinary catheter drainage bag and by having a CNA stand over another resident while feeding them. Both actions were against the facility's policies and procedures.
The facility failed to ensure the safe administration of IV fluids for two residents by not labeling IV dressings with the date of insertion or the nurse's initials, leading to potential complications such as infection.
A resident with respiratory failure and a history of traumatic brain injury did not receive necessary respiratory care as the t-piece was not connected to the oxygen regulator, risking respiratory distress. The oversight was confirmed by staff and highlighted a failure to follow the facility's respiratory protocol.
The facility failed to ensure a licensed nurse did not leave an insulin pen unattended and did not accurately document a controlled drug record for a resident. The insulin pen was left on a WOW while the nurse entered a resident's room. Additionally, discrepancies were found in the controlled-drug record for a resident's Lacosamide (Vimpat) medication, which were not identified and reported as required by the facility's policy.
The facility failed to ensure PRN orders for psychotropic medications were necessary and limited to a specific duration for two residents. One resident was prescribed lorazepam without a stop date, and another had a PRN order exceeding the 14-day limit, contrary to the facility's policy and consultant pharmacist's recommendations.
The facility staff failed to implement its infection control program for two residents. A suction canister for one resident was not replaced per policy, and urinal bottles for another resident were not labeled as required. These deficiencies were confirmed through observations and interviews with staff.
The facility failed to ensure timely transmission of MDS assessments to CMS for four residents, resulting in assessments remaining in an exported status without successful validation and acceptance. The previous MDSC left abruptly without completing the necessary transmission process or providing a handoff report, leading to potential delays in care and services.
The facility failed to ensure the MDS accurately reflected a resident's use of a mitten restraint, despite the presence of an order and informed consent. This inaccuracy was confirmed by the DON and could potentially delay necessary care.
Failure to Verify Oxygen Purity After Medical Gas Line Repair
Penalty
Summary
The facility failed to ensure that all 24 residents who were dependent on mechanical ventilators received oxygen that was verified to be free of contaminants after a repair to the medical gas line system. On the date of the incident, an oxygen alarm was triggered in the Subacute Unit, which led to the discovery of a broken oxygen line. The facility's census at the time included 24 residents in the Subacute Unit who were reliant on mechanical ventilation for respiratory support. Following the repair of the oxygen line by a contracted service, the facility returned the oxygen gas line to service without conducting required quality testing or verification by a certified medical gas verifier. Interviews with facility staff, including the Facilities Director and the Regional Compliance Officer, confirmed that no certified medical gas verifier was called to inspect, test, or verify the oxygen gas line after the repair. The Facilities Director, who is not certified as a medical gas verifier, made the decision to return the system to service based on his own judgment and background in electrical and biomedical engineering. The last documented oxygen gas quality testing had been performed over a month prior, and annual testing was the facility's standard practice. No documentation was available to confirm the safety, purity, or integrity of the medical gas system following the repair. The residents affected by this deficiency had significant medical histories, including chronic respiratory failure, traumatic brain injury, stroke, anoxic brain injury, and other conditions requiring continuous mechanical ventilation. Many had tracheostomies and feeding tubes, and were entirely dependent on the facility's oxygen supply for survival. Despite the critical nature of their conditions, the facility did not follow required protocols for post-repair verification of the medical gas system, as outlined in NFPA 99, which mandates thorough leak testing, purging, and functional testing by a certified third-party verifier after any repair or modification to a medical gas piping system.
Failure to Implement Effective Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to fully develop and implement an effective antibiotic stewardship program (ASP) as part of its Infection Prevention and Control Program (IPCP). Specifically, the facility did not establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria, such as Loeb's minimum criteria, before initiating antibiotic treatment. The facility also did not have a standardized process for using the antibiotic tracking sheet or for documenting the use of Loeb's criteria in their policies and procedures. A resident was admitted with multiple diagnoses, including acute hypoxic respiratory condition and hyperlipidemia, and was dependent on staff for several activities of daily living. The resident was prescribed levofloxacin for a urinary tract infection (UTI), but the only documented symptoms were increased heart rate and fever. According to the Infection Preventionist (IP), these symptoms alone did not meet Loeb's minimum criteria for initiating antibiotics for a UTI in residents without a urinary catheter. The IP acknowledged that there was no protocol in place to ensure that Loeb's criteria were consistently applied or documented when antibiotics were prescribed. Interviews with staff revealed a lack of awareness and use of standardized criteria for antibiotic initiation. The IP and Registered Nurse (RN) involved did not consistently use or document evidence-based criteria when reviewing or initiating antibiotic orders. The facility's policies and procedures on antimicrobial stewardship did not specify the use of the antibiotic tracking sheet or Loeb's criteria, and the Manager of Infection Prevention was not aware of the CMS requirements for antibiotic stewardship regulation.
Failure to Rotate Subcutaneous Injection Sites for Insulin and Heparin
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were receiving subcutaneous injections of insulin and heparin. For one resident with a history of craniotomy, hypertension, and chronic respiratory failure, records showed that heparin injections were repeatedly administered in the same anatomical sites, specifically the left and right upper quadrants, without proper rotation. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that the administration sites were not rotated as required by standards of practice and the manufacturer's guidelines, which state that injection sites must be rotated to prevent adverse skin reactions. The facility's own policy also mandates rotation of injection sites for subcutaneous medications. Similarly, another resident with a history of stroke, tracheostomy, and ventilator-dependent respiratory failure received insulin glargine injections in the same sites, specifically the left lower quadrant and left upper arm, over multiple administrations. Interviews with nursing staff and review of records confirmed that injection sites were not rotated for this resident either, contrary to both manufacturer guidelines and facility policy. The staff acknowledged that failure to rotate sites could lead to skin complications and affect medication absorption. Both residents were dependent on staff for medication administration and had significant cognitive or physical impairments, requiring total or substantial assistance with activities of daily living. The lack of site rotation for subcutaneous injections was directly observed in medication administration records and confirmed by staff interviews, demonstrating a failure to adhere to professional standards and facility policy for medication administration.
Deficient Practices in Enteral Feeding Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care and services for residents receiving enteral feeding, resulting in several deficiencies related to infection control and accurate delivery of prescribed nutrition. For one resident with a feeding tube, the medication syringe used for administering medications was not labeled with the date it was to be changed, contrary to facility practice and infection prevention protocols. Both the registered nurse and the infection preventionist confirmed that syringes are to be changed daily and labeled accordingly, and the absence of a date on the syringe was identified during observation and interview. Another resident with a percutaneous endoscopic gastrostomy tube had a water flush bag that was not changed within the 24-hour period recommended by the manufacturer's guidelines. Observations and interviews with nursing staff confirmed that the water flush bag had been hanging for more than 24 hours, and both the licensed vocational nurse and registered nurse acknowledged that this practice could lead to contamination. The infection preventionist also stated that the water flush bag should have been changed according to the manufacturer's instructions, as outlined in the facility's procedures. A third resident receiving continuous tube feeding did not receive the accurate amount of tube feeding formula as ordered by the physician. Review of the resident's intake flowsheet and direct observation revealed a discrepancy between the amount of formula delivered and the amount that should have been administered according to the prescribed rate and duration. Nursing staff were unable to provide documentation accounting for the difference, and there were no new orders to hold or adjust the feeding. Facility policy required monitoring and documentation to ensure accurate delivery of enteral nutrition, which was not followed in this instance.
Failure to Maintain Respiratory Equipment and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to maintain safe and appropriate respiratory care for three residents by not adhering to infection control practices and equipment maintenance protocols. For two residents with tracheostomies and on continuous oxygen therapy, surveyors observed that the oxygen tubing was in direct contact with the floor. Both the Infection Preventionist and nursing staff confirmed that oxygen tubing should not touch the floor due to contamination risks, and facility policy required proper infection control practices to be followed. In another instance, a resident receiving humidified oxygen therapy via a T-piece had an oxygen humidification bottle that was not labeled with the date it was last changed. Staff interviews revealed that humidification bottles are required to be changed every three days and must be labeled accordingly, but there was no documentation or label present to indicate when the bottle was last replaced. The absence of labeling and documentation was confirmed by both the respiratory therapist and nurse manager, who stated that this omission was not in line with facility policy and created uncertainty about the maintenance of the equipment. Additionally, a resident's Yankauer suction tool was found to be open, containing yellow secretions, and not labeled with the date it was opened or needed to be changed. Nursing staff acknowledged that the Yankauer should be changed daily or as needed and must be dated, but in this case, there was no way to determine when it was last replaced. Facility procedures required regular changing and dating of such equipment, but these were not followed, as confirmed by staff interviews and policy review.
Failure to Rotate Injection Sites for Insulin and Heparin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous injection sites for insulin and heparin, as required by standards of practice and manufacturer guidelines. For two residents, staff repeatedly administered injections in the same anatomical locations over an extended period. Documentation and interviews confirmed that the same sites were used for multiple administrations, rather than rotating among recommended areas such as the abdomen, upper arms, or thighs. One resident, who had a history of craniotomy, hypertension, chronic respiratory failure, and was non-verbal with severely impaired cognition, received heparin injections for DVT prophylaxis. Review of medication administration records showed that heparin was repeatedly injected into the same abdominal quadrants without rotation. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that this practice did not follow facility policy, standards of practice, or manufacturer instructions, all of which require site rotation to prevent adverse skin reactions and ensure proper medication absorption. Another resident, with a history of stroke, tracheostomy, ventilator dependence, and severely impaired cognition, received insulin glargine injections. Records indicated that insulin was administered multiple times in the same anatomical sites, such as the left lower quadrant and left upper arm, without rotation. Staff interviews and review of manufacturer guidelines confirmed that injection sites should have been rotated for each administration. Facility policies also specified the requirement for site rotation, and the failure to do so was acknowledged as a medication error by nursing staff.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as evidenced by several observed deficiencies. Towels used for sanitizing were not stored according to facility standards; some were left on carts in the tray line area rather than being placed in clean towel bins, sanitizer buckets, or dirty towel bins. Staff acknowledged that these towels could be contaminated and should not have been left out, as this practice could lead to cross contamination. The facility did not have a specific policy for towel use, but staff confirmed that towels should only be in sanitization buckets when in the kitchen. Food items in the walk-in refrigerators were not consistently labeled or stored according to facility policy. Expired prepackaged sandwiches were found in the refrigerator, and a pan of cooked meat was left partially uncovered and unlabeled. Additionally, a container of sour cream had an illegible expiration date, and staff could not confirm its safety. The facility's policy requires all food to be labeled, dated, and rotated using the first-in, first-out method, with expired or unlabeled items to be discarded, but these procedures were not followed. Personal property of staff, including a cell phone, headphone case, and an uncovered serrated knife, was found stored on a cart next to food items in the kitchen. Staff admitted that personal items should be kept in lockers and that knives should be covered and stored properly. Furthermore, refrigerator and freezer temperature logs showed that several units were repeatedly out of the acceptable temperature range, with no corrective actions documented. This included both excessively high and low temperatures, which were not addressed as required by facility policy.
Failure to Follow Contact Precautions for Resident on Isolation
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program by not ensuring that staff and medical providers followed contact precautions for a resident on contact isolation. Specifically, a registered nurse, nurse practitioner, and medical doctor entered the room of a resident with a diagnosis of carbapenem-resistant pseudomonas aeruginosa (CRPA) and multidrug-resistant pseudomonas aeruginosa (MDRA) without donning gowns, despite a posted contact isolation sign instructing all staff and visitors to wear gowns and gloves before entry. The staff members did not wear gowns because they believed it was unnecessary since they did not intend to touch the resident. The resident involved had a complex medical history, including prostate cancer, chronic respiratory failure with a tracheostomy, and a percutaneous endoscopic gastrostomy tube. The resident was dependent on staff for all activities of daily living and had limited ability to communicate. Physician orders were in place for contact isolation due to the presence of CRPA and MDRA, both of which are infectious bacteria that require strict adherence to contact precautions to prevent transmission. Interviews with facility staff, including the infection preventionist and nurse manager, confirmed that the facility's policy required anyone entering the room of a resident on contact isolation to wear a gown, regardless of whether direct contact with the resident or environment was anticipated. The failure of the RN, NP, and MD to don gowns was acknowledged as a violation of facility policy and procedures regarding contact isolation, as outlined in the facility's infection control policies.
Failure to Cover Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter had their catheter drainage bag left uncovered and visible from the hallway. The resident, who had a history of respiratory failure, cerebrovascular accident, hypertension, and neurogenic bladder dysfunction, was severely cognitively impaired and required extensive assistance with daily activities. The resident's care plan specifically included an intervention to provide a privacy bag for the catheter drainage bag, but this was not implemented at the time of observation. During the observation, a Licensed Vocational Nurse confirmed that the drainage bag should have been covered with a dignity bag to protect the resident's privacy. A Registered Nurse also stated that maintaining dignity includes covering urinary drainage bags. Facility policies reviewed indicated that the use of a dignity cover is required to protect resident privacy and dignity, and that residents have the right to considerate, compassionate, and respectful care. The failure to cover the drainage bag was directly observed and acknowledged by staff as not meeting these standards.
Failure to Obtain Informed Consent for Psychotropic Medication Dose Increase
Penalty
Summary
The facility failed to obtain informed consent prior to increasing the dose of Seroquel, a psychotropic medication, for one resident. The resident, who had a history of respiratory failure, tracheostomy, hypertension, and diabetes mellitus, was cognitively impaired and required significant assistance with daily activities. The resident was taking antipsychotic medication for psychosis, which manifested as agitation and pulling out medical devices. The medication order was changed to increase the nightly dose of Seroquel from 50 mg to 75 mg, but the facility did not obtain a new informed consent for the increased dose. Interviews with nursing staff confirmed that the last documented consent was for the previous 50 mg dose, and that facility policy required informed consent for any new psychotropic medication order or dose increase. Staff acknowledged that consent should be verified with the resident's family, especially given the resident's impaired decision-making capacity, to ensure understanding of the risks and benefits. Review of facility policies further supported the requirement for informed consent prior to the use or dose change of psychotropic medications.
Failure to Ensure Call Light Within Reach for Non-Verbal Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident who was non-verbal, had a tracheostomy, severely impaired cognition, and required total assistance with all activities of daily living. The resident's call light was observed hanging on the enteral feeding pole, out of the resident's reach, during a room observation. Both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light was not placed within reach, with the CNA stating she had forgotten to do so after providing morning care. The facility's policy requires that call lights be within reach of residents at all times to ensure safety and timely assistance. The resident involved had significant medical needs, including a history of craniotomy, hypertension, chronic respiratory failure, and was assessed as having severely impaired cognition. Despite these needs, staff did not follow the facility's policy regarding call light placement, as confirmed by interviews with nursing staff and the Infection Preventionist. The failure to place the call light within reach was directly observed and acknowledged by staff, constituting a failure to reasonably accommodate the resident's needs and preferences.
Failure to Complete Restraint Assessments Prior to Use
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints without proper assessment and documentation. For one resident with acute respiratory failure, traumatic brain injury, and schizophrenia, a right-hand peek-a-boo mitten was applied to prevent self-harm or injury by pulling at medical devices. However, there was no restraint assessment completed prior to the application of the mitten, as confirmed by both the Minimum Data Set Nurse (MDSN) and the Nurse Manager (NM). The facility's policy required a restraint assessment and documentation of least restrictive alternatives before restraint use, but this was not followed. Another resident with a history of stroke, tracheostomy, and ventilator-dependent respiratory failure was subjected to bilateral soft wrist restraints and peek-a-boo mittens after previously removing a tracheostomy. Similar to the first case, there was no restraint assessment completed prior to the application of these devices. The MDSN and NM both confirmed that the required pre-restraint assessment and documentation of unsuccessful least restrictive interventions were not performed, despite the facility's policy mandating these steps. In both cases, the lack of a pre-restraint assessment and failure to attempt or document less restrictive interventions were identified through record review, staff interviews, and policy review. The facility's own policy outlined the need for assessment, documentation, and the use of least restrictive alternatives, but these procedures were not followed for either resident prior to the application of physical restraints.
Failure to Maintain Catheter Tubing Without Dependent Loops
Penalty
Summary
A resident with a history of neurogenic bladder, gastrostomy, and tracheostomy, who required total assistance with all activities of daily living and had an indwelling suprapubic catheter, was observed to have a urinary drainage bag hanging on the side of the bed with a dependent loop in the catheter tubing. The resident's medical records confirmed the presence of a physician's order for suprapubic catheter care every shift and as needed, with specific instructions for catheter maintenance. During the observation, a registered nurse confirmed the presence of the dependent loop and acknowledged that the tubing should be positioned to avoid such loops to ensure free urine flow. Further interviews with facility staff, including the Infection Preventionist, confirmed that facility policy and standard infection prevention practices require catheter tubing to be free of kinks or loops to prevent obstruction of urine flow. The facility's policy on urinary catheter care specifically states that the urinary collection bag should always be positioned below the bladder without dependent loops or kinks. The failure to maintain the catheter tubing in accordance with these guidelines constituted a deficiency in providing appropriate care and services to prevent urinary tract infections.
Insulin Order Lacked Required Indication
Penalty
Summary
A deficiency was identified when a resident was found to be receiving a hypoglycemic medication, specifically insulin lispro, without a documented indication for its use. The resident had a history of respiratory failure and diabetes mellitus and was admitted to the facility with these diagnoses. Review of the resident's records showed that while the order for insulin glargine included an indication for diabetes, the order for insulin lispro did not specify a reason for administration. This omission was confirmed during interviews with nursing staff, who acknowledged that the medication order lacked the required indication. Further review of the facility's policy on medication administration and monitoring revealed that staff are required to observe the seven rights of medication administration, which includes ensuring the right reason (indication) is documented. The absence of an indication for insulin lispro in the resident's medication order was inconsistent with both facility policy and standard medication administration practices, as confirmed by staff interviews and record review.
Improper Handling and Storage of Medication Bubble Pack
Penalty
Summary
A deficiency was identified when a medication cart inspection revealed that a resident's cyanocobalamin (vitamin B12) bubble pack had a broken seal and was covered with clear plastic tape. The registered nurse present confirmed that the process for dispensing medication from a bubble pack requires licensed nurses to compare the medication label with the medication administration record (MAR) before dispensing. If a medication is dispensed by accident, it should be immediately discarded in the designated bin inside the medication room, not taped back into the bubble pack. In this case, medications from two slots in the bubble pack had been removed and then taped back, rather than being discarded as required. The nurse manager confirmed awareness of the issue and reiterated that taping a dispensed medication back into the bubble pack is not acceptable, as it could result in contamination and uncertainty about whether the correct medication was returned. The facility's policy and procedure on medication storage states that contaminated or improperly sealed medications must be immediately removed and disposed of. The failure to follow these procedures resulted in the presence of a contaminated medication in the medication cart, creating the potential for medication errors.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to fully develop and implement an effective antibiotic stewardship program (ASP) as part of its Infection Prevention and Control Program. Specifically, the facility did not establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria, such as Loeb's minimum criteria, before initiating antibiotic treatment. The facility's policy and procedure on antimicrobial stewardship did not include guidance on the use of antibiotic tracking sheets or the application of Loeb's criteria, and staff interviews confirmed that there was no standardized protocol in place for these processes. A resident was readmitted with multiple diagnoses and was dependent on staff for several activities of daily living. The resident was prescribed levofloxacin for a urinary tract infection (UTI), but review of the resident's clinical presentation showed only increased heart rate and fever, which did not meet Loeb's minimum criteria for initiating antibiotics for UTI in residents without a urinary catheter. The Infection Preventionist (IP) acknowledged that the resident did not meet the criteria and that this was not documented or communicated according to a standardized protocol, as the facility's policy did not specify these requirements. Further interviews revealed that staff, including a registered nurse covering for the IP, did not use any standardized criteria when reviewing antibiotic use. The Manager of Infection Prevention was unaware of CMS requirements for antibiotic stewardship and confirmed that the facility's ASP was not fully aligned with regulatory expectations. The facility's policy stated the intent to optimize antibiotic therapy but lacked specific protocols for evaluating and documenting the appropriateness of antibiotic use.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to document that the pneumococcal vaccine was offered to a resident and that education regarding the vaccine was provided to the resident's family or decision-maker, as required by the facility's policy and procedures. Specifically, for a resident admitted with respiratory failure and seizure disorders, who was rarely able to make herself understood or understand others, there was no documentation in the medical record indicating that the vaccine was offered or that education was provided to the family or legal representative. The Infection Preventionist confirmed the absence of documentation during a review of the resident's records. Further investigation revealed that a registered nurse, who was covering for the Infection Preventionist, had discussed the vaccine with the resident's family member and obtained consent for administration but failed to document this discussion or enter the vaccine order as required. The facility's policy mandates that education about the benefits and potential side effects of the pneumococcal vaccine be provided and documented, and that the offer of immunization be recorded in the resident's medical record. This lapse in documentation was confirmed through interviews and record reviews with facility staff.
Failure to Accurately Document Physical Restraint Use in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) accurately reflected the use of physical restraints. Specifically, a resident with a history of respiratory failure, tracheostomy, hypertension, and diabetes mellitus, who was cognitively impaired and required significant assistance with activities of daily living, had physician orders for bilateral hand mittens and soft wrist restraints to prevent self-injury by pulling at medical devices. Despite these orders and the actual use of restraints, the MDS assessments on multiple occasions did not correctly indicate the use of restraints, with some assessments coded as 'not used' when restraints were in place and in use daily. Observations and interviews confirmed that the resident was using both mittens and wrist restraints, and staff acknowledged the purpose was to prevent the resident from interfering with their oxygen and tracheostomy equipment. The MDS nurse admitted that the MDS Section P: Restraints and Alarms was not coded correctly on at least two assessment dates, despite the presence of restraint orders and ongoing use. Facility policy and CMS procedures require that the MDS accurately reflect the resident's status, but this was not followed, resulting in inaccurate documentation of restraint use for the resident.
Failure to Notify Physician of Resident's Hematuria
Penalty
Summary
The facility failed to notify the physician about a resident's continued hematuria while on blood thinner medication. The resident, who had an indwelling urinary catheter and was on Apixaban, experienced hematuria from January 12 to January 15, 2024. Despite the presence of blood clots and the resident's deteriorating condition, the attending physician was not informed, which led to a delay in appropriate medical intervention. On January 15, 2024, the resident required an emergency transfer to a general acute care hospital due to elevated body temperature, abdominal distention, and significant hematuria. Upon arrival at the hospital, the resident was diagnosed with septic shock, a urinary tract infection, and pneumonia. The hospital records indicated that the resident had a high fever, rapid heart rate, and dark red urine with a foul odor. Interviews with the Nurse Manager and the attending physician confirmed that the physician was not notified of the resident's ongoing hematuria, which was a significant change in condition. The facility's policies required prompt notification of the physician for such changes, but this protocol was not followed, contributing to the resident's severe health decline.
Failure to Notify Physician of Resident's Hematuria
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter (IUC) and on blood thinner medication received appropriate care to prevent complications. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with an IUC and was on Apixaban for atrial fibrillation. Despite orders to monitor for hematuria and manage continuous bladder irrigation (CBI) to prevent clot formation, the resident continued to have hematuria from 1/12/2024 to 1/15/2024 without the physician being notified of the ongoing bleeding, which was a significant change in condition. This lack of communication led to the resident's condition worsening, requiring emergency transfer to a hospital where the resident was diagnosed with septic shock, UTI, and pneumonia. The resident's medical records indicated that the urine characteristics were described as red, light, and with clots on multiple occasions, yet the physician was not informed. The facility's policy required notifying the physician of any significant change in the resident's condition, including marked changes in vital signs or symptoms. However, the licensed nurses failed to inform the physician about the resident's continued hematuria, which was critical given the resident's anticoagulant therapy and the potential for severe complications. Interviews with the Nurse Manager and the physician confirmed that the physician was not notified about the resident's ongoing hematuria, which would have prompted a reassessment of the resident's medication and possibly an earlier transfer to the hospital. The facility's failure to adhere to its policies on change of condition notification and indwelling urinary catheter care and management directly contributed to the resident's emergency hospitalization and subsequent diagnoses of severe infections and septic shock.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not complete an assessment for the risk of entrapment prior to the use of four bed siderails (SR) in the raised position for three residents. Additionally, the facility did not obtain a physician's order or informed consent for the use of these restraints and bed alarms. These deficiencies were observed in three out of four sampled residents during the review of physical restraints care area. For Resident 24, the facility did not have an assessment, physician's order, or informed consent for the use of four bed siderails in the raised position. The resident had severe cognitive impairment and was totally dependent on staff for all activities of daily living. Despite being at medium risk for falls and high risk for injury, the facility did not document any assessment for possible entrapment with the use of the siderails. Staff interviews confirmed that the siderails were used for the resident's safety, but the necessary documentation and consents were missing. Resident 23, who had a history of post-traumatic cervical-spine injury and quadriplegia, was also found with four siderails in the raised position and a bed alarm in place without the required physician's order or informed consent. The resident was at medium risk for falls and high risk for injury. Similarly, Resident 5, who had a history of alcohol abuse and multiple brain hemorrhages, was found with four siderails in the raised position and a bed alarm without the necessary documentation. Staff interviews revealed a lack of understanding regarding the need for physician's orders and informed consents for the use of these restraints, which were implemented to prevent falls and injuries.
Failure to Develop and Implement Care Plans for Bed Alarms, Side Rails, and Medications
Penalty
Summary
The facility failed to develop and implement care plans for the use of bed alarms and side rails for several residents. Resident 23, who was admitted with respiratory failure and quadriplegia, was observed with four side rails raised and a bed alarm in place, but no care plan was created for these devices. Similarly, Resident 5, admitted with a history of alcohol abuse and multiple brain hemorrhages, was also observed with four side rails raised and a bed alarm in place without a corresponding care plan. Both the Licensed Vocational Nurses and the Nurse Manager confirmed the absence of care plans for these residents, which is against the facility's policy that mandates an interdisciplinary care plan within seven days of admission. Resident 24, who had a traumatic brain injury and was dependent on staff for all activities of daily living, was also found to have four side rails raised without a care plan. The Infection Preventionist and the Nurse Clinician verified the absence of a care plan for the use of side rails. The facility's policy requires accurate clinical documentation and the creation of an interdisciplinary care plan within seven days of admission, which was not followed in this case. Additionally, Resident 37, admitted with ischemic stroke and dependent on a ventilator, did not have care plans addressing the use of apixaban (Eliquis) and an indwelling urinary catheter. The Nurse Manager confirmed the absence of these care plans, stating that without them, the facility could not set treatment goals or implement necessary interventions. The facility's policy emphasizes the importance of clinical documentation and interdisciplinary care plans, which were not adhered to in these instances.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers/injuries for three residents. Resident 23, who was admitted with a history of sacral decubiti ulcers and venous insufficiency, had missing wound assessments, measurements, pictures, and care plan reviews during specific weeks. The Registered Nurse (RN) responsible for these assessments was on vacation, and the facility was short-staffed, leading to the omission of necessary wound care documentation and assessments. The Nurse Manager confirmed the importance of timely assessments and reporting to monitor wound progression and involve the interdisciplinary team when necessary. Resident 27, admitted with a diagnosis of respiratory failure and a history of diabetes mellitus and obesity, also had missing wound assessments, measurements, and care plan reviews for several weeks. The RN acknowledged the importance of following weekly wound assessments and documentation to track wound progression and inform the doctor or wound specialist if there was a worsening of the pressure injury. The Nurse Manager reiterated that the treatment nurses should perform weekly wound assessments, including taking pictures and reviewing the pressure injury care plan, to monitor the wound's condition. Resident 14, admitted with a diagnosis of respiratory failure and a history of diabetes mellitus and massive intraparenchymal hemorrhage, had missing assessments and pictures for moisture-associated skin damage (MASD) during a specific week. The RN stated that they do not measure the wound but take weekly pictures for MASD. The Nurse Manager emphasized the importance of timely assessment and reporting to monitor the wound for worsening or healing and involve the interdisciplinary team and attending physician when necessary. The facility's policy and procedure for pressure injury and skin breakdown assessment and prevention were not consistently followed, leading to the potential for development and worsening of pressure ulcers/injuries for the residents involved.
Failure to Properly Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three residents. For Resident 24, the enteral feeding bottle was not labeled with the correct date and time it was started, and the water flush bag lacked the date and time it was started and the prescribed rate. This was verified by Registered Nurse 2 and the Nurse Manager, who confirmed that the labeling was necessary to ensure the formula was not expired and the water flush bag was discarded after 24 hours as per the facility's procedure. Resident 24 had severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs). The resident's physician's orders included specific instructions for hydration and continuous tube feeding, which were not properly followed due to the labeling deficiencies. For Resident 26, the enteral feeding bottle did not indicate the rate prescribed by the physician, and the water flush bag was not labeled with the resident's name, room number, rate prescribed by the physician, and the date and time it was hung. Licensed Vocational Nurse 3 verified these deficiencies and stated that all tube feeding formulas and water flush bags should be properly labeled to ensure the correct amount of feeding and water flushes were administered. Resident 26 had severe cognitive impairment, was non-verbal, and totally dependent on staff for all ADLs. The resident's physician's orders included specific instructions for hydration and continuous tube feeding, which were not properly followed due to the labeling deficiencies. For Resident 191, similar deficiencies were observed. The enteral feeding bottle did not indicate the rate prescribed by the physician, and the water flush bag was not labeled with the resident's name, room number, rate prescribed by the physician, and the date and time it was hung. Licensed Vocational Nurse 3 verified these deficiencies and emphasized the importance of proper labeling. Resident 191 had severe cognitive impairment, was unable to follow commands, and was totally dependent on staff for all ADLs. The resident's physician's orders included specific instructions for tube feeding and water flushes, which were not properly followed due to the labeling deficiencies.
Failure to Ensure Safe Use of Bed Side Rails
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed side rails for three residents. For Resident 24, the facility did not conduct an assessment for the risk of entrapment, did not review the risks and benefits of side rails with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff stated this was for the resident's safety to prevent falls. However, there was no physician's order or care plan indicating the use of side rails, and the facility did not consider side rails as restraints, contrary to their policy and manufacturer's guidelines. For Resident 23, the facility also failed to assess the risk of entrapment, did not review the risks and benefits with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff acknowledged that a physician's order and consent should have been obtained. The facility's policy and manufacturer's guidelines were not followed, which required evaluation for entrapment risk and proper documentation. Similarly, for Resident 5, the facility did not conduct an assessment for entrapment risk, did not review the risks and benefits with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff confirmed there was no physician's order or documented assessment. The facility's policy and manufacturer's guidelines were again not adhered to, which emphasized the need for proper evaluation and documentation to prevent serious injury or death.
Failure to Follow Proper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices in three specific instances. First, a Food Service Attendant (FSA) was observed working in the food production line without wearing a hair restraint. During an interview, the FSA confirmed that he was not wearing a hair restraint and acknowledged the importance of doing so to prevent hair from falling into the food. The facility's policy requires all employees in food production, storage, and serving areas to wear hair restraints to avoid food contamination and maintain a professional appearance. This policy was not adhered to in this instance. Second, an observation of refrigerator 1-2 revealed open food items not in their original packaging and placed in clear storage bags without labels or dates. The Kitchen Supervisor (KS) confirmed that these items were pieces of cheddar cheese and stated that all food items not in their original packaging must be labeled with the specific name, the date they were opened, and the initials of the food service attendant who opened them. Third, an open package of low moisture part-skim mozzarella cheese was found without an open date. The KS confirmed that the cheese should have been labeled with an open date to ensure it is used before it expires. The facility's policy mandates that all foods be labeled and dated appropriately to ensure proper storage and safety of the food supply. These deficiencies had the potential to place six out of 43 residents at risk for foodborne illnesses.
Failure to Implement Antimicrobial Stewardship Policy
Penalty
Summary
The facility failed to implement its antimicrobial stewardship (AMS) policy and procedures for a resident when clindamycin was ordered indefinitely and the facility did not monitor the antibiotic use for 77 days. The resident, who had a history of multidrug-resistant pseudomonas proteus and MRSA, was admitted on 12/28/2023. The physician's order dated 1/29/2024 indicated clindamycin 1% gel to be applied twice daily for chronic respiratory failure, with the length of therapy marked as indefinite. The Medication Administration Record (MAR) showed that the antibiotic was administered multiple times from January to April 2024 without a stop date or monitoring as part of the AMS program. During interviews, the Infection Preventionist and Nurse Manager acknowledged that antibiotics should not be used indefinitely and should have a stop date to prevent antibiotic resistance. They confirmed that Resident 2's clindamycin use should have been included in the AMS program to ensure proper monitoring and documentation. The facility's policy, last revised in June 2023, emphasized the importance of optimizing antibiotic therapy to improve clinical outcomes and minimize unintended consequences such as drug resistance. However, the facility did not adhere to this policy, leading to the deficiency in monitoring antibiotic use for the resident.
Failure to Honor Residents' Dignity
Penalty
Summary
The facility failed to honor the residents' right to a dignified existence for two sampled residents. For Resident 23, the facility did not ensure that the resident's indwelling urinary catheter drainage bag was covered with a dignity bag, making the urine visible to visitors and other residents' family members. This was observed during a visit where the drainage bag was hanging visibly from the bed without a dignity cover. Both the Licensed Vocational Nurse and the Nurse Manager confirmed that the drainage bag should have been covered to protect the resident's privacy and dignity, as per the facility's policy and procedure. For Resident 238, the facility failed to ensure that a Certified Nursing Assistant (CNA) was not standing over the resident while assisting with feeding. The CNA was observed standing over the resident, who had a history of cerebrovascular accident and was non-verbal, while feeding them. The CNA acknowledged that they should have been seated at eye level to convey respect and maintain the resident's dignity. The Nurse Manager also confirmed that the CNA should have been seated to ensure proper monitoring of the resident during feeding, as outlined in the facility's feeding procedure manual.
Failure to Label IV Dressings
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents, leading to potential complications. Resident 21, admitted with diagnoses including respiratory failure and a history of sepsis, had an unlabeled peripheral IV line on their right arm. The IV dressing lacked the date of insertion or the initials of the nurse who inserted or changed it. This oversight was confirmed by both a respiratory therapist and a registered nurse, who acknowledged that the absence of labeling could result in staff not knowing when to change the dressing or start a new line, potentially leading to infection. Similarly, Resident 238, admitted with diagnoses including respiratory failure and a history of pulmonary embolism and septic shock, also had an unlabeled peripheral IV line on their right hand. A certified nursing assistant and a licensed vocational nurse both confirmed that the IV dressing was not dated or initialed. They recognized that this failure could prevent staff from knowing when to change the dressing or start a new line, increasing the risk of infection. The facility's policy on vascular access management, which requires dressings to be labeled with the date of insertion and changed every seven days or sooner if soiled, was not followed. The nurse manager confirmed that the lack of labeling could lead to missed dressing care or new insertions, potentially resulting in complications such as phlebitis and cellulitis.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for Resident 34. The resident, who was admitted with a diagnosis of respiratory failure and had a history of traumatic brain injury, required oxygen therapy to maintain oxygen saturation levels above 92%. However, during an observation, it was found that the resident's t-piece was not connected to the oxygen regulator, which is essential for delivering the prescribed oxygen concentration. This oversight was confirmed by Registered Nurse 1, who acknowledged that the t-piece should have been connected to the oxygen regulator with the humidifier to administer the required oxygen concentration. The failure to connect the t-piece could lead to respiratory distress for the resident. Further interviews revealed that the Nurse Manager stated the respiratory therapist should have ensured the t-piece was reconnected to the oxygen regulator after providing a breathing treatment. The facility's policy on respiratory protocol, last reviewed in June 2019, indicated the need for proper assessment and connection of respiratory equipment. The deficiency in reconnecting the t-piece to the oxygen regulator was deemed unsafe and had the potential to cause respiratory compromise for Resident 34.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that a licensed nurse did not leave an insulin pen unattended on top of a computer on wheels (WOW). During an observation, a Licensed Vocational Nurse (LVN) placed an insulin pen on the WOW and walked away, leaving it unattended while entering a resident's room. The LVN acknowledged that the insulin pen should have remained with her at all times for safety. The facility's policy indicated that medications must remain with the administering staff at all times and not be left unattended. Additionally, the facility failed to ensure accurate documentation of a controlled drug record for a resident. The resident, admitted with respiratory failure and seizure disorder, had a physician's order for Lacosamide (Vimpat) to be administered via g-tube. A review of the controlled-drug record revealed discrepancies in the documented amounts of the medication administered and the remaining amount. Both a Registered Nurse (RN) and the Nurse Manager confirmed the inaccuracies and stated that the discrepancy should have been identified and reported per the facility's policy. The facility's policy required a physical inventory of all controlled medications at each shift change and immediate reporting of any discrepancies to the Director of Nursing.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were only used when necessary and limited to a specific duration for two residents. Resident 23 was admitted with a history of respiratory failure, post-traumatic cervical-spine injury, quadriplegia, and septic shock. The resident had an active diagnosis of depression and was prescribed lorazepam 0.5 mg every 6 hours PRN for anxiety without a specified stop date. Despite recommendations from the consultant pharmacist to specify a stop date, the order remained open-ended, and the facility did not follow up on the pharmacist's recommendation. The Nurse Manager confirmed that the lorazepam order did not have a stop date and acknowledged that psychotropic drugs should only be prescribed for a 14-day duration to avoid unnecessary use and potential side effects. Resident 5 was admitted with a diagnosis of gastrointestinal bleed and had a history of agitation and delirium. The resident was prescribed lorazepam 1 tablet every 12 hours PRN for anxiety, with a start date and a stop date extending beyond the 14-day limit. The Nurse Manager confirmed that the lorazepam order for Resident 5 exceeded the 14-day duration and acknowledged the risk of prolonged use of psychotropic medications. The consultant pharmacist had reviewed the medications and recommended specifying a stop date, but this recommendation was not implemented. The facility's policy on psychotropic drugs indicated that PRN psychotropic medications should have a start and stop date for 14 days initially, followed by re-evaluation by a physician. However, this policy was not adhered to in the cases of Residents 23 and 5, leading to the potential for unnecessary use of psychotropic drugs and associated adverse consequences. The failure to follow the consultant pharmacist's recommendations and the facility's own policy resulted in a deficiency in the management of PRN psychotropic medications for these residents.
Failure to Implement Infection Control Program
Penalty
Summary
The facility staff failed to implement its infection control program for two residents. For Resident 5, the suction canister, which was labeled with the date 4/5/2024, was not discarded and replaced per facility policy. The policy required the suction canister to be changed weekly to prevent the growth and transmission of infection. During an observation and interview, it was confirmed that the suction canister should have been changed on 4/12/2024, but it was not. The Nurse Manager confirmed that the canister should be changed weekly to prevent bacterial growth that could cause infections in vulnerable residents. For Resident 3, the urinal bottle was not labeled with the resident's name, date, and room number as required by the facility's policy. During an observation and interview, two unlabeled urinal bottles were found hanging on the left side rail of the resident's bed. The Certified Nursing Assistant confirmed that the urinals should be labeled to prevent interchanging and potential infection. The Nurse Manager also confirmed that the urinals should be labeled to prevent switching with other residents and to know when to change them. The facility's infection control policy emphasized the importance of labeling to minimize the risk of disease transmission.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were successfully transmitted timely to the Centers for Medicare and Medicaid Services (CMS) for four out of 14 sampled residents. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments for Residents 12, 18, 23, and 27 were not successfully transmitted and accepted by CMS. The Minimum Data Set Coordinator (MDSC) verified that the assessments remained in an exported status and had not been reconciled, resulting in no CMS final validation reports for the assessments. The previous MDSC had left abruptly without completing the necessary transmission process or providing a handoff report of pending assessments, leading to this issue. Resident 12 was originally admitted on 12/6/2021 and readmitted on 11/22/2022 with diagnoses including traumatic brain injury, cardiac arrest, and PEG placement. The resident's MDS assessments dated 3/1/2023, 6/1/2023, 9/1/2023, and 12/1/2023 were not successfully transmitted to CMS. The MDSC confirmed that the validation reports for these assessments were not reconciled, and the assessments were not accepted by CMS. The Nurse Manager (NM) also verified the status of these assessments and acknowledged the lack of a handoff report from the previous MDSC. Resident 18, admitted on 9/25/2020 and readmitted on 6/2/2023, had diagnoses including chronic respiratory failure, tracheostomy, and PEG placement. The resident's MDS assessments dated 12/4/2022, 3/4/2023, 8/29/2023, and 11/29/2023 were also not successfully transmitted to CMS. Similar to Resident 12, the MDSC and NM confirmed that the validation reports were not reconciled, and the assessments were not accepted. Additionally, Residents 23 and 27, both with diagnoses of respiratory failure, had their MDS assessments in an exported status without successful transmission and acceptance by CMS. The MDSC acknowledged the importance of reconciling and submitting the MDS assessments timely to ensure proper billing and provision of necessary care and services for the residents.
Inaccurate MDS Documentation for Resident Restraint Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one of the sampled residents, specifically Resident 24. The MDS did not document the use of a mitten restraint, which was applied to prevent the resident from self-harm by pulling out medical devices. Resident 24 had a history of traumatic brain injury, dysphagia, PEG placement, and chronic respiratory failure, and was totally dependent on staff for all activities of daily living. Despite the presence of an order for the mitten restraint and informed consent from the family, the MDS assessment did not reflect this restraint use, which was confirmed by the Director of Nursing (DON) during a review of the resident's records. Observations and interviews with nursing staff confirmed that the mitten restraint was in use for Resident 24's safety. The DON acknowledged that the MDS was inaccurately coded, which could potentially delay the provision of necessary care. The facility's failure to document the restraint use in the MDS assessment is a deficiency that could negatively impact the resident's plan of care and the delivery of services.
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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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