Redding Post Acute

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and sanitary kitchen environment for food preparation for all residents consuming food prepared by the kitchen. Surveyors observed that the perimeter walls of the kitchen at counter height and below, including pipes, drains, electrical coverings, and flooring, were covered with a buildup of food particles and adhered grime. Paint was chipped, peeling, and worn on the walls, sink, and around the flooring. The exterior sides of the stove/oven were unclean with cooked-on grime, and rolling dollies holding buckets of kitchen supplies were dirty with black filth. In the walk-in refrigerator, the flooring was buckled and uneven, with an open, unjoined seam down the middle that revealed a vein of rust; when the area was cleaned, rust material puddled from under and between the seam and spread across the floor. Review of the facility’s policies titled “General Cleaning of Food & Nutrition Services Department” and “Sanitation,” both dated 2023, showed that floors were required to be maintained in good condition, walls and ceilings washed thoroughly, heavily soiled surfaces cleaned as necessary, and all equipment kept clean and in good repair. During concurrent observation and interview, the Food and Nutrition Manager confirmed that the kitchen’s perimeter walls, pipes, drains, electrical coverings, flooring, rolling dollies, and exterior of the stove were dirty, that paint was chipped, peeling, and worn on walls, sink, and around flooring, and that the walk-in refrigerator flooring was buckled, uneven, and had a rust vein that oozed and puddled when cleaned. In a separate interview, the RD confirmed the kitchen was dirty and reported that she had written reports documenting the lack of general cleanliness and sanitation. The report stated these failures had the potential to incite harmful growth of unhealthy microorganisms resulting in foodborne illness among residents consuming food from the kitchen, which could lead to sickness and disease.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency related to environmental safety in wing three shower rooms, where spray bottles of bleach cleaner solution were stored in unlocked cabinets above the toilets among toiletry items. Observations on 2/17/26 at 2:00 pm showed that both shower room one and shower room two had spray bleach bottles in these unsecured cabinets, with no locks visually present or available. The facility’s policies titled "Homelike Environment" (dated February 2021) and "Safety and Supervision of Residents" (revised July 2017) state that residents are to be provided with a safe environment and that resident safety and accident prevention are facility-wide priorities. During a concurrent observation and interview with the ADON on 2/17/26 at 2:05 pm in shower room two, the ADON confirmed that shower room one is used as a shower/tub room for residents and shower room two is used by staff for equipment storage, but both rooms were set up in the same manner with unlocked cabinets containing bleach. The ADON acknowledged that only shower room one directly affects residents as a safety concern and stated that cabinets are usually locked, though neither cabinet was locked at the time and no locks were visible. In subsequent interviews, the DON and Administrator each confirmed that cabinets containing chemicals such as bleach should be locked for resident safety, and the Housekeeping/Laundry Supervisor stated that the spray bleach is used by CNAs and nursing staff, is kept in the shower room cupboards for cleaning, and should be stored in locked cabinets.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident’s right to a dignified existence when staff did not ensure her eyeglasses were kept clean. The resident was admitted with muscle weakness and difficulty walking, and her MDS indicated she wore glasses and had a BIMS score of 10/15, reflecting moderate cognitive impairment. During an observation and interview, the resident’s eyeglasses were noted to be covered in smears, and she reported that she had informed staff that her glasses needed to be cleaned but no one had done so, making it hard for her to see. The facility’s Resident Rights policy, revised October 2025, stated that residents are guaranteed a dignified existence, and the DON stated that her expectation was that staff clean residents’ eyeglasses daily. This failure could have resulted in a decrease in the resident’s vision and emotional well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to revise and implement a comprehensive care plan to include the ordered use of TED hose for one cognitively intact resident with diagnoses including pulmonary edema, irregular heart rate, and muscle weakness. Facility policies required goals and objectives to be reviewed and/or revised upon readmission and for the care plan to specify services needed to attain or maintain the resident’s highest practicable well-being. The resident was originally admitted and later readmitted with physician orders dated 3/6/24 and 2/8/26 directing that CNAs apply below-the-knee TED hose on in the morning and off in the evening. However, during review of the resident’s care plan dated 11/17/26, the DON confirmed that the application of TED hose had been resolved on a previous care plan and was not included on the current care plan, despite the ongoing physician orders. Surveyor observations and interviews showed that the TED hose were not being consistently applied as ordered and that documentation was inaccurate. On one observation, the resident stated she was supposed to have TED hose on every morning when getting out of bed, but CNA 1, who had been working with the resident for two months, reported not knowing the resident was supposed to receive TED hose in the mornings. On another day, the resident again reported that TED hose were not applied that morning. Review of the MAR for February 2026 showed that LNs 1 and 2 documented that TED hose were applied when they were not; LN 1 admitted charting that the TED hose were on when they were not, and LN 2 stated she assumed the CNA had put them on without actually seeing them on the resident. The DON confirmed that the TED hose were not applied despite MAR entries indicating otherwise, and the MAR also documented that the resident had pitting edema in her legs for 11 out of 17 days in February.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure safe storage and proper handling of medications for two residents. For one resident with a lower leg fracture and diabetes, who had a BIMS score of 15 indicating good decision-making ability, medications brought from home were found stored in stapled store pharmacy paper bags on the top right-hand side of a locked cabinet in the medication room. The facility’s policy titled “Medications Brought to the Facility by the Resident/Family” stated that the facility ordinarily does not permit residents and families to bring medications into the facility. During observation and interview, LN 3 confirmed that the bags contained this resident’s medications, acknowledged that the facility did not usually store outside medications in store pharmacy bags or inside a cabinet in the medication room, and did not know how they came to be stored there. The DON later stated that when family brings in medications from home, the facility asks them to take the medications back home and that these medications should not have been stored in the medication room cabinet. The second deficiency involved another resident with depression and high blood pressure, who had a BIMS score of 13 indicating good decision-making ability. During observation of medication cart 1 with LN 2, a medication cup containing pills was found loose in the top right-hand drawer of the cart. LN 2 stated that the medications were for this resident, who had refused to take them earlier in the day. The facility’s “Storage of Medications” policy indicated that drugs and biologicals are to be stored in the packaging, containers, or other dispensing systems in which they are received. In a subsequent interview, the DON stated that no medications should be kept in a medication cup inside the medication cart and that when a resident will not take medications, the medications should be disposed of.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of the admission Minimum Data Set (MDS) for one resident when the MDS indicated the resident had no hearing difficulty, despite multiple sources indicating otherwise. Documentation in the resident's referral packet, discharge summary, and initial assessments by the activities director and speech therapist all noted that the resident was hard of hearing or had trouble hearing out of the right ear. The MDS Coordinator confirmed that the admission MDS inaccurately reflected the resident's hearing status as having no difficulty, despite evidence from the speech therapy evaluation and activities assessment indicating otherwise. Interviews with the resident's family member and facility staff revealed that there was no visible indication in the resident's room about the hearing impairment, and staff did not appear to be aware of the resident's hearing difficulties. The MDS Coordinator acknowledged that the information used to complete the MDS should have included input from various assessments and documentation, which would have shown the resident was hard of hearing. The failure to accurately assess and document the resident's hearing status on the admission MDS was confirmed through record review and staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop an individual, written care plan addressing hearing loss for one resident with documented hearing impairment. The resident was admitted with a history of left hip replacement and dependence on supplemental oxygen, and was not their own responsible party. Despite information in the referral packet and assessments by the Activities Director and Speech Therapist indicating the resident was hard of hearing, no care plan was created to address this need. The Registered Nurse job description assigned responsibility for care plan development, but this was not carried out for the resident's hearing loss. Interviews with the resident's family member revealed that staff were unaware of the resident's hearing impairment, and the communication board in the room was left blank. The Director of Nursing confirmed the absence of a hearing loss care plan after reviewing the resident's records. The lack of a care plan for hearing loss had the potential to place the resident at risk for social isolation and mood or behavior disorders, as staff were not informed or guided on how to address the resident's communication needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to administer supplemental oxygen as prescribed for one resident with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. The resident's care plan and physician's orders specified that oxygen saturation should be maintained between 88% and 94%. However, review of the Medication Administration Records (MAR) revealed that on 66 out of 84 documented occasions, the resident's oxygen saturation was above 94% and the physician was not notified as required by the order. The Director of Nursing confirmed that staff did not follow the prescribed parameters for oxygen administration and failed to notify the physician when the resident's oxygen saturation exceeded the ordered range. The facility's policy required staff to verify and review physician orders for safe oxygen administration, but this was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the rights and dignity of a resident who identified as female and had a history of dysarthria following a stroke, transsexualism (transgender), and aphasia. The resident was her own responsible party and had a care plan indicating her female gender identity. Despite facility policies and training requiring staff to treat residents with respect and use their preferred gender identity and pronouns, a Certified Nurse Assistant (CNA) was witnessed verbally abusing the resident. Specifically, CNA B told the resident to "shut the [F word] up" and made derogatory remarks about the resident's gender identity, referencing her transition from male to female. This incident was reported by another CNA who intervened to stop the abuse. Observations and interviews with the resident revealed significant emotional distress following the incident. The resident, who had a low BIMS score indicating poor memory, became visibly upset, fearful, and unable to discuss the event in detail. She displayed signs of fear, such as trembling hands, watery eyes, and avoidance of eye contact, and confirmed through nonverbal cues and limited verbal responses that the incident had occurred and continued to affect her. Further interviews with CNA B showed a continued lack of respect for the resident's gender identity, as evidenced by the repeated use of incorrect pronouns and an aggressive tone during questioning. Facility policies explicitly prohibit discrimination against LGBT residents and require the use of preferred pronouns, but these were not followed in this case, resulting in a violation of the resident's rights and dignity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was served at appropriate temperatures, as required by their own policies and regulatory standards. Multiple interviews revealed that a resident and a family member both reported that food was often served cold, with the family member confirming they personally witnessed cold food being served. Another resident, who was cognitively intact according to her BIMS score, stated that her food was always cold and expressed disappointment during a meal observation, pushing her tray away and referencing ongoing complaints about food temperature at Resident Council meetings. Record reviews and staff interviews further substantiated the deficiency. The Certified Dietary Manager (CDM) acknowledged missing temperature documentation on several days and was observed writing temperatures on logs after being asked for them, rather than at the time food was served. The CDM and cook both described procedures for taking and documenting food temperatures, but logs reviewed showed missing entries for multiple meals. The Registered Dietician confirmed that temperatures were supposed to be taken and documented prior to tray line assembly, but this was not consistently done. These actions and inactions led to the failure to serve food at safe and appetizing temperatures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's consultant pharmacist (CP) failed to identify and report an irregularity in a physician's order for cyclobenzaprine, a muscle relaxant, for a resident who was admitted with a left hip replacement and chronic pulmonary edema. The physician's order specified cyclobenzaprine 5 mg by mouth every eight hours as needed for pain and muscle spasms in both legs, but the medication administration record (MAR) did not document the specific indication—whether it was given for pain or muscle spasms—each time the medication was administered. The facility's policy required the CP to review medication orders monthly and report any irregularities, including medications without adequate monitoring, to the physician for review. During the monthly medication regimen review, the CP did not identify or report the lack of documentation regarding the indication for cyclobenzaprine administration. In an interview, the CP acknowledged that there was no documentation indicating the reason for each administration of cyclobenzaprine and admitted this was a missed opportunity to catch the irregularity during the review. The deficiency was identified for one resident, and no irregularities were reported for cyclobenzaprine prior to the resident's discharge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its abuse reporting policy when an allegation of witnessed verbal abuse toward a resident was not reported to the California Department of Public Health (CDPH), the local Ombudsman, or the police department. According to the facility's policies and procedures, all suspected allegations of abuse are required to be reported to these entities. The incident involved a Certified Nurse Assistant (CNA) overhearing another CNA verbally abusing a resident by making derogatory and inappropriate comments about the resident's gender identity and using profane language. The witnessing CNA reported the incident to the charge nurse and the administrator, but the administrator and Director of Nursing (DON) later stated that the allegation was never reported to them, and thus, no report was made to the required agencies. The resident involved had a history of dysarthria following a cerebral infarction, transsexualism (transgender identity), and aphasia, and was her own responsible party. The resident's care plan identified her as female. The failure to report the witnessed verbal abuse as required by policy resulted in a delay in investigation and did not ensure the resident's protection from further harm during the investigation process, as outlined in the facility's procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medical records for a resident were filed in an accessible manner, as required by regulation. During a review of the resident's electronic and paper medical records, key documents such as the "Inventory of Personal Possessions" and the admission "History and Physical" were missing and could not be located when requested. The Director of Nursing (DON) indicated these documents should have been in the paper chart in the medical records department, but they were not present. Later, the "History and Physical" was found in the Admissions office, and the location of the "Inventory of Personal Possessions" was not explained. Additionally, the facility was unable to provide a policy and procedure regarding the completeness, accuracy, and presence of medical records when requested. The facility also failed to ensure that medical records did not leave the premises without proper authorization. It was observed and confirmed that a physician had taken a resident's medical records home, which is not permitted unless expressly authorized by the Department. This action resulted in a delay in locating the resident's "History and Physical" and had the potential for the medical records to become lost. The lack of accessible and properly stored medical records caused delays in medical record accessibility for the resident, who had a history of left hip replacement and required supplemental oxygen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident was admitted with a left hip replacement and required supplemental oxygen. Upon review of the resident's electronic medical record, the admission History and Physical (H&P) was not present. The Director of Nursing (DON) indicated that the H&P should be in the paper medical record, but it was not found during an initial review of the paper chart. The Medical Records (MR) staff also confirmed the absence of the H&P in the paper chart. Later, the DON located the H&P in the Admissions office and explained that the physician sometimes took H&Ps home and returned them later. The absence of the required admission H&P in the resident's medical record at the time of review constituted the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurses' notes were meaningful, informative, and consistent for one resident. Specifically, the daily skilled charting notes documented the resident's hearing as adequate, while the weekly progress notes indicated the resident was hearing impaired and hard of hearing. This inconsistency in documentation was confirmed by the Director of Nursing during a review of the resident's records. The resident involved had a history of left hip replacement and required supplemental oxygen. The facility's policy required accurate and thorough assessment of residents' health status, but a policy specifically addressing the accuracy of medical records was requested and not provided. The inconsistent documentation of the resident's hearing status had the potential for the resident's specific care needs to go unmet.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the inventory list for a resident's personal effects and valuables was complete, as required by regulation. Upon review, the inventory list for one resident was found to be missing signatures from both the responsible party and the facility staff who completed it. The Director of Nursing confirmed that the responsible party had not signed the inventory list at either admission or discharge, and the staff member's signature on the discharge section was illegible and could not be identified. Additionally, the responsible party stated that the inventory list was never reviewed or provided at either admission or discharge. Further review of the resident's records revealed that the resident was not their own responsible party and had been admitted with a left artificial hip joint and dependence on supplemental oxygen. The responsible party was present during the discharge process, as documented in the general notes, yet the required signatures were still missing from the inventory list. The facility's policy indicated that Certified Nurse Assistants were responsible for completing the form, but the specific staff member involved could not be identified. This deficiency was identified through interviews and record reviews, which demonstrated that the facility did not follow its own policy or regulatory requirements for documenting and verifying residents' personal property inventories. The lack of proper documentation and signatures had the potential for personal belongings not to be accurately accounted for, as directly stated in the report.

Plan Of Correction

1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A 100% audit of all current residents' most recent MDS assessments was initiated to ensure accuracy of sensory and communication sections (hearing and vision). Any discrepancies identified were corrected, and care plans were updated accordingly. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All MDS staff and licensed nurses involved in assessment and data collection were re-educated on: - Accurate completion of the MDS per RAI (Resident Assessment Instrument) guidelines. - Verifying resident sensory status through observation, resident/family interview, and review of medical records prior to submission. The MDS Coordinator and DON will ensure that each admission and significant change MDS is reviewed for accuracy before final submission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, of at least three (3) randomly selected MDS assessments to verify accuracy in the sensory section. Audit results will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any errors identified will be corrected immediately, and staff involved will receive retraining as needed. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A facility-wide audit was conducted of all residents identified with hearing deficits to ensure that appropriate, individualized care plan interventions are in place. Any missing or incomplete care plan items were immediately corrected by the IDT. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. Licensed nurses and members of the IDT were re-educated on the requirement to develop and update individualized care plans that address all assessed resident needs, including sensory impairments such as hearing or vision loss. The MDS Coordinator and DON will ensure that any sensory deficits identified on the MDS trigger an appropriate care plan intervention. Newly admitted residents with hearing or vision concerns will have their care plans initiated within 48 hours of admission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, to verify that residents with hearing deficits have active, individualized care plan interventions addressing communication and social engagement needs. Audit findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified deficiencies will be corrected immediately, and additional education provided as necessary. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. Prior to discharge, the resident's condition was stable, and no adverse effects were noted related to the oxygen administration. The attending physician was notified of the incident and made aware of the resident's discharge status. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents receiving supplemental oxygen were reviewed to ensure oxygen is being administered per the current physician's order. Any discrepancies were immediately corrected, and physicians were notified as needed. No other residents were identified as affected. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A facility-wide in-service training was provided to all licensed nurses regarding proper administration and titration of supplemental oxygen according to physician orders, documentation of oxygen saturation readings, and the notification protocol for oxygen levels outside the ordered range. The Nursing Supervisor or designee will verify that all oxygen therapy orders clearly specify flow rate and target oxygen saturation range. All new and readmitted residents with oxygen orders will have those orders reviewed by the Director of Nursing (DON) or designee to ensure clarity and completeness. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will perform weekly audits for four (4) weeks, then monthly for two (2) months, to ensure residents receiving oxygen are administered therapy per physician orders. Audit results will be reviewed during the Quality Assurance and Performance Improvement. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #3 was immediately assessed by the licensed nurse for physical and emotional well-being following the incident. The resident denied injury or distress related to the event. Emotional support was offered if needed, and the attending physician was notified. The alleged perpetrator (CNA A) was immediately suspended pending investigation, and the allegation was reported to the California Department of Public Health (CDPH) and the Long-Term Care Ombudsman as required. The facility completed an internal investigation, and appropriate disciplinary action was taken based on the findings. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents were interviewed and observed for signs of distress, fear, or mistreatment. No additional residents reported or displayed evidence of abuse or neglect. Staff were reminded to immediately report any allegations, suspicions, or observations of abuse to the charge nurse and administration per facility policy. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All facility staff will receive re-education on the Abuse Prevention Policy, including definitions, examples of verbal abuse, resident rights, and mandatory reporting procedures. Education emphasized that any form of disrespectful, degrading, or threatening language toward residents is strictly prohibited. The facility reinforced a zero-tolerance policy for abuse. New hires will receive abuse reporting training during orientation and annually thereafter. The DON and Administrator will ensure that all allegations are promptly investigated, and corrective actions are implemented as required by regulation. The DON or designee will conduct random staff and resident interviews weekly for four (4) weeks, then monthly for two (2) months, to ensure that residents feel safe and that staff adhere to the facility's Abuse Prevention Policy. All findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified issues will result in immediate corrective action and retraining. --- 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A review of the previous seven (7) days of temperature logs was conducted to identify any inconsistencies. No additional adverse findings were noted. The kitchen staff were instructed to verify and document meal temperatures before every tray line service to ensure food is served within the safe and acceptable temperature range. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A comprehensive re-education was provided to all dietary staff regarding proper food holding, monitoring, and serving temperatures in accordance with state and federal food safety standards. Staff were re-trained on the requirement to record and document hot and cold food temperatures before each meal service. The Food Service Director or designee will conduct temperature audits before each meal service daily for two (2) weeks, then three times per week for the following four (4) weeks, and weekly for two (2) months thereafter. Audit results will be reviewed with the Director of Nursing (DON) and Administrator. Test trays will go out at least twice a week to varied staff with test tray slip to document temperature, presentation, and taste. CDM will make corrections based off test tray notes. Findings will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate staff retraining or disciplinary action, as appropriate. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A comprehensive audit of all current medication orders was completed by the Director of Nursing (DON) and Consultant Pharmacist to identify any potential irregularities or incomplete medication indications. Any identified discrepancies were clarified with the attending physician, and orders were corrected as needed. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Consultant Pharmacist was re-educated on their regulatory responsibility to review all monthly medication orders for accuracy, appropriate indications, and potential irregularities. - The Consultant Pharmacist has changed the protocol at the Pharmacy for any muscle relaxant medication to only be approved for a diagnosis of muscle spasms. - Licensed nurses were re-educated on the requirement to ensure all PRN (as-needed) medication orders specify the indication for use (e.g., pain, spasm, anxiety) and to clarify any vague or incomplete orders with the prescribing provider. - All new orders will be reviewed daily (Monday-Friday) using an order listing report at our IDT meeting. Any discrepancies will be corrected and/or clarified at that time. - The DON will ensure new medication orders are reviewed upon admission and during monthly medication regimen reviews for accuracy and completeness. - A process was implemented for the Consultant Pharmacist to document any identified irregularities and corresponding physician responses in the monthly review reports. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct monthly medication order audits for three (3) months to ensure orders are complete, accurate, and free from irregularities. Audit results will be reviewed during Pharmacy & Therapeutics and QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate correction and re-education. Continued compliance will be monitored through ongoing monthly pharmacist reviews. 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. A review of all abuse allegation reports from the past 60 days was conducted to ensure proper and timely notification to CDPH, the Ombudsman, and law enforcement. No additional discrepancies were identified. The facility confirmed that all other incidents were appropriately reported in accordance with regulatory requirements. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses, department heads, and supervisors were re-educated on the facility's Abuse Prevention, Reporting, and Investigation Policy, emphasizing immediate reporting requirements to CDPH, the Ombudsman, and law enforcement within mandated timeframes. - The Abuse Reporting Checklist was updated to include verification boxes for required notifications. --- 4. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was located and properly filed in the designated medical records storage area on the same day the issue was identified. The record was reviewed for completeness and accuracy, and no missing documentation was found. The resident experienced no negative outcomes related to this deficiency. 5. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A facility-wide audit of all residents' medical records was completed to ensure that all records were filed accurately and were easily accessible. No additional misplaced or inaccessible records were found. 6. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Health Information Manager (HIM) and Medical Records Clerk were re-educated on the facility's policy and procedure for medical record management, including filing, accessibility, and secure storage. - A Medical Record Location Log has been implemented for tracking temporary removal of charts (e.g., for audits, MD review, or IDT meetings). - A sign-out system will be maintained to ensure all records are returned promptly to their designated storage area. - The Administrator and DON will ensure that any new or updated records are filed daily. Education was provided to department heads on how to properly request and return resident charts through the HIM department. 7. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was promptly retrieved and returned to the facility upon discovery. The record was reviewed for completeness and accuracy, and no missing documentation was identified. Resident #1 experienced no adverse outcomes because of this deficient practice. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A complete audit of all current resident medical records was conducted to ensure that all records were on site and properly secured. No additional records were found to be missing or removed from the facility. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The facility's policy and procedure for medical record management was reviewed and revised to clearly state that resident medical records must always remain on facility grounds. - The Medical Director and attending physicians were re-educated on this policy, with emphasis that no original records are to leave the facility under any circumstances. - If a physician requires information for off-site review, photocopies or secure electronic copies will be provided by the Health Information Manager (HIM). - The Health Information Manager and Administrator will monitor compliance by verifying that all records remain on-site. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' "Daily Skilled Charting" to ensure that assessments accurately reflected residents' actual functional and sensory statuses. Any discrepancies identified were immediately corrected, and nurses responsible were re-educated on accurate documentation practices. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses were re-educated by the Director of Nursing (DON) on the importance of completing accurate and meaningful daily skilled charting that reflects each resident's current condition, including hearing, vision, and communication abilities. - The facility Daily Skilled Nursing Documentation Policy was reviewed and updated to include specific guidance on validating sensory documentation against current care plans and assessments. - The MDS Coordinator will ensure consistency between MDS assessments, care plans, and daily skilled documentation. - Any identified inaccuracies during documentation reviews will result in immediate correction and staff retraining. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' personal inventory forms to ensure each form was complete, current, and signed by both facility staff and the responsible party. Any missing signatures or incomplete forms were corrected immediately. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Charge Nurses were re-educated on the facility's Resident Personal Property and Inventory Policy, emphasizing that both the staff member completing the inventory and the responsible party (or resident, if applicable) must sign and date the inventory form upon admission and discharge. - The facility updated the Admission Checklist to include a verification step ensuring the inventory form is signed by both parties before completion of the admission process. - The Social Services Director and Admissions Coordinator will ensure that any changes to resident belongings during the stay are documented and signed accordingly. - The Director of Nursing (DON) will review the process quarterly to ensure compliance. Element #5: Completion Date. November 21, 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly follow up and report the results of an x-ray for a resident who experienced a fall and subsequent knee injury. The resident, who had a history of cognitive impairment and other medical conditions, fell and injured her left knee, prompting a physician to order an x-ray. Despite the x-ray being completed, the facility did not receive or follow up on the results for two days, during which the resident experienced severe pain due to a broken bone. The delay in obtaining and reporting the x-ray results led to a delay in treatment, causing the resident to endure unnecessary pain. The Director of Nursing confirmed that the facility had not received the x-ray report and had not taken steps to follow up with the imaging company within the expected timeframe. This oversight resulted in the resident's physician not being notified of the x-ray results until two days after the x-ray was performed, highlighting a deficiency in the facility's process for managing and communicating critical diagnostic information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the rights of Resident 1 by not providing a written notice of a proposed room change, as required by their policy. Resident 1, who was cognitively intact and capable of making her own decisions, was moved from her room without receiving a written notice or explanation for the change. The move was decided by the Admission Department and the Social Service Department to accommodate new residents, specifically males, and Resident 1 was informed that she had no choice in the matter. This lack of communication and disregard for Resident 1's preferences led to her experiencing distress and frustration. During interviews, Resident 1 expressed her dissatisfaction and emotional distress over the move, stating that she did not want to relocate and felt like she had no control over her life. The Social Service Director (SSD) and Director of Nursing (DON) admitted that they did not provide a written notice to Resident 1 and were unaware of the requirement until reviewing the Federal Regulations. The situation was further complicated by the presence of Resident 1's Personal Therapist, who confirmed that Resident 1 was upset and did not agree to the move. The facility's failure to adhere to their policy and federal regulations resulted in a deficiency in protecting Resident 1's rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. Resident #72 was admitted with a history of serious mental health conditions, including bipolar disorder and major depressive disorder. Despite a Level II Preadmission Screening and Resident Review (PASRR) evaluation recommending specialized services, the MDS inaccurately indicated that the resident did not have a serious mental illness. This oversight was acknowledged by the MDS Coordinator, who admitted that the PASRR Level II was missed in the admission MDS. Resident #65 was admitted with a history of chronic obstructive pulmonary disease and hypertension. The admission MDS inaccurately reported that the resident did not use tobacco, despite progress notes and the resident's own admission indicating they were a smoker. The MDS Coordinator acknowledged the error, stating that she misunderstood the resident's smoking status during the initial interview. Both the Director of Nursing and the Administrator expressed expectations for MDS accuracy to ensure appropriate care, but the inaccuracies in these assessments were not aligned with those expectations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who had received a new psychiatric diagnosis prior to readmission. The resident, who had a history of dementia with behavioral disturbance, was readmitted to the facility after a psychiatric stay with a new diagnosis of unspecified psychosis. Despite this new diagnosis, the facility did not complete a new PASRR upon the resident's return. The facility's policy required that all admissions have the appropriate PASRR completed, but this was not adhered to in the case of the resident. The resident's medical record showed no evidence of a new PASRR being completed after readmission, nor was there a referral made to the appropriate state-designated authority following the new psychiatric diagnosis. Interviews with facility staff, including the Director of Nursing (DON) and the Social Services Director (SSD), revealed a lack of clarity and training regarding the PASRR process, contributing to the oversight. The DON acknowledged that a new PASRR should have been completed when the resident was readmitted with a diagnosed mental illness of psychosis. The facility's process involved reviewing admissions for medications and diagnoses that would trigger a positive Level I PASRR, but this was not effectively executed in this instance. The DON admitted to a lack of training and understanding of the PASRR requirements, which led to the deficiency in the resident's care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with schizophrenia. The resident was admitted to the facility with a medical history that included schizophrenia and major depressive disorder, both with onset dates matching the admission date. However, the Level I PASRR completed at the hospital prior to admission only listed depression as a serious diagnosed mental disorder, omitting schizophrenia. This omission led to the state being unable to complete a Level II evaluation, as the resident was not considered to have a serious mental illness according to the PASRR. Interviews with facility staff revealed that the hospital was responsible for completing the initial Level I PASRR, and the Director of Nursing (DON) was tasked with ensuring its accuracy before admission. Despite this, the schizophrenia diagnosis was not captured, and the PASRR was accepted as completed by the hospital. The DON acknowledged the need to redo and resubmit the PASRR to include the schizophrenia diagnosis. The facility's policy indicated that all admissions should have the appropriate PASRR completed, but this was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident admitted for comfort care, resulting in a distressing experience for the resident. The resident, who was terminally ill and admitted for end-of-life care, was left in a soiled state with a loud television and was not assisted with eating. Despite the resident's request not to be placed in a brief, he was found in a soiled brief and hospital gown, with dried brown rings on his bed sheets, indicating prolonged neglect. The resident was admitted with conditions such as thrombocytopenia and an infected pacemaker and was aware of his surroundings, as noted in his admission assessment. He had an indwelling urinary catheter and was continent of bowel and bladder. However, during the night shift, the resident was not provided with the requested bedpan and was left in a diaper, contrary to his expressed wishes. The resident also reported that the television was excessively loud, and his requests for it to be turned down were ignored, contributing to his discomfort and inability to rest. Interviews with staff and family members revealed that the resident's needs were not adequately addressed. The resident's family found him in a distressing state the following morning, leading to his decision to leave the facility and return to the hospital. The facility's failure to adhere to the resident's preferences and provide necessary care, such as assistance with meals and maintaining a comfortable environment, resulted in a significant deficiency in the quality of care provided.