River Pointe Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 6041 Fair Oaks Blvd, Carmichael, California 95608
- CMS Provider Number
- 056101
- Inspections on file
- 59
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at River Pointe Post-acute during CMS and state inspections, most recent first.
A resident with anxiety, depression, and physical disability but intact cognition experienced misappropriation of property when a CNA repeatedly solicited and received money and used the resident’s debit card for personal purchases. Bank records and text messages showed multiple money requests and transactions tied to the CNA, while facility notes documented the resident’s emotional distress, social withdrawal, and loss of interest in activities following discovery of the financial losses. The resident reported feeling pressured to provide money, stated she had not authorized the extent of withdrawals, and indicated she had not been informed by the facility not to give money to staff, despite staff interviews and facility policy confirming that asking for or accepting money from residents is prohibited and considered potential financial abuse.
A resident with mobility limitations and dependence on staff for shower transfers did not receive scheduled showers as required by their ADL care plan and facility policy. Documentation showed missing or incomplete weekly shower records and only one shower per week over several weeks, despite staff statements that all residents are scheduled for twice-weekly baths with refusals documented. The resident and a family member reported multiple missed showers and that the resident sometimes went an entire week with only one shower, without having requested reduced frequency, contrary to facility expectations for maintaining personal hygiene.
A contracted phlebotomist failed to follow contact precautions while drawing blood from a resident with an MRSA sacral wound infection who had physician-ordered contact precautions in place. The phlebotomist entered the room and performed a blood draw without wearing a gown, left the room and handled phlebotomy equipment without changing gloves or performing hand hygiene, then returned to continue the procedure. The phlebotomist was unable to describe required contact precautions and subsequently entered another resident’s room to draw blood without cleaning the equipment, contrary to facility policy and expectations stated by the IP and DON.
A resident with a known banana allergy experienced an anaphylactic reaction after being served Banana Cream Pie, despite clear documentation of the allergy in their records and meal ticket. The incident required emergency administration of epinephrine, and staff interviews confirmed that established procedures to prevent allergen exposure were not followed.
A resident with upper extremity impairment and cognitive intactness was not assisted with her dentures before breakfast, despite her care plan indicating a need for substantial help. The CNA who served her breakfast was unaware of the resident's dentures, and the DON acknowledged the importance of this assistance for proper nutrition.
Three unlabeled medication cups containing white cream were found on a resident's dresser, with staff confirming the cream was not labeled and should not have been left at the bedside. The resident reported the cream was lidocaine applied by a nurse, and the DON acknowledged this was not acceptable practice according to facility policy requiring medications to be stored in locked compartments.
A resident with severe cognitive impairment, hemiplegia, and a high fall risk was left unsupervised in their room without a 1:1 sitter, as required by their care plan. The resident was found sitting on the edge of the bed with the call light on the floor and no staff present, despite needing assistance with meals and continuous supervision. Staff confirmed the supervision requirement and that the assigned sitter had left the resident unattended.
A resident with intact cognitive function and significant medical needs experienced delays in staff response due to a malfunctioning call light system. When the resident activated the call light, only the light above the room door illuminated, while the corridor call lights failed to activate. Staff confirmed the issue and noted that the system had not been reprogrammed after servicing, and the problem had not been reported to maintenance or leadership.
A resident with cognitive and communication deficits was physically assaulted by another resident known for daily aggressive behaviors, resulting in a bruise and visible fear. Despite care plans addressing the aggressor's history of anger and aggression, staff confirmed ongoing verbal and physical abuse, and the vulnerable resident was not protected from harm.
Two residents, one with violent behavior and another with dementia, were involved in a physical and verbal altercation. An LPN witnessed the incident and reported it to a supervisor, but the required abuse report was not filed with authorities as mandated by facility policy and state law.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A CNA was scheduled and worked with an expired certification, as confirmed by employee file review and staff interviews. The DSD acknowledged the lapse in tracking certification renewals, and the DON stated that a system should be in place to prevent such occurrences. This failure resulted in non-compliance with state requirements for CNA certification.
A resident with severe cognitive impairment and a staff member did not have documented evidence of being offered or receiving the COVID-19 vaccine, nor was there documentation of refusal or contraindication. Facility staff confirmed that required procedures for offering and documenting COVID-19 vaccination were not followed for these individuals, despite policy requirements.
Three residents did not receive scabies medications as ordered: one did not receive prescribed Permethrin or Ivermectin, another received Permethrin on two consecutive days instead of once, and a third experienced a delay in Permethrin administration without documentation. The ADON confirmed these deviations from physician orders and facility policy.
A resident with a suspected scabies infection was removed from contact precautions before receiving the prescribed Permethrin cream treatment, contrary to physician orders and facility policy. Staff confirmed that the resident had not received the required medication and that contact isolation was discontinued prematurely, despite the presence of visible rashes.
A resident in an LTC facility was struck on the hand by another resident, resulting in a bruise. The incident occurred when the second resident, who was severely cognitively impaired, entered the first resident's room, leading to a physical altercation. The first resident, who was cognitively intact, attempted to push the second resident's wheelchair out of the room, prompting the strike. The second resident had a history of aggressive behavior and was on psychotropic medications. Facility policies on abuse prevention and altercations were not effectively implemented to prevent this incident.
A CNA failed to wear a protective gown while changing a resident's soiled brief, violating the facility's infection control policy. The resident, admitted with a skin infection and an indwelling Foley catheter, required Enhanced Barrier Precautions to prevent the spread of multi-drug resistant organisms. The Infection Preventionist confirmed the necessity of gown use during high-contact care.
A facility failed to maintain food safety standards, risking contamination for 105 residents. Issues included an unclean ice machine, improperly stored kitchenware, unlabeled and expired food, and incorrect thawing processes. Dietary staff lacked knowledge of dishwashing procedures, and a staff member violated the dress code by not fully covering their hair.
The facility failed to properly dispose of garbage and refuse, as observed with two outside dumpsters that were not adequately closed, and the surrounding area was littered with debris. Observations with the Dietary Supervisor and Environmental Services Manager confirmed that the dumpster lids were open, and there was scattered trash around the area. The Registered Dietitian emphasized the need for closed lids and a clean surrounding area to prevent pests and rodents.
The Dietary Services Supervisor (DS) failed to demonstrate necessary competencies in food safety procedures, including proper thawing of meats, correct sanitizer concentration for dishwashing, and maintaining hair restraint in the kitchen. Observations revealed improper thawing practices and inadequate knowledge of sanitizer use, with expired ServSafe certification. The facility administrator plans to address these issues under the QAPI program.
A Dietary Aide in an LTC facility demonstrated inadequate competency in dishwashing procedures, failing to correctly use test strips and verbalize proper manual dishwashing steps. This posed a risk to 105 out of 108 residents who consumed food from the facility, despite the aide having attended relevant training and holding a valid food handler certificate.
The facility failed to follow the planned menu, resulting in dietary discrepancies for residents. Two residents on large portion diets received fewer meatballs than prescribed, while four residents on renal diets were served pudding instead of cookies. Additionally, residents on low fat and low cholesterol diets received whole milk and margarine, and those on finger food diets were given rice and tapioca pudding instead of the specified items. None of the residents received the parsley garnish as indicated on the menu.
The facility failed to adhere to professional standards for two residents. A resident's medications were left unattended, contrary to policy, without a Medication Administration Assessment or care plan documentation. Another resident's oxygen tubing was found unconnected, resulting in inadequate oxygen delivery. Both incidents were against facility policies, as confirmed by staff interviews.
The facility failed to ensure a safe environment by not having a smoking policy or supervising two residents with respiratory conditions who smoked on the premises. The ADON acknowledged the absence of policies and the risk of accidents, including fire. Additionally, a resident's care plan did not address smoking safety, despite the need for supervision being noted in their assessment.
A facility was found to have a 20.69% medication error rate when a nurse improperly administered medications to a resident with a PEG tube. The nurse crushed and combined medications, failing to flush the tube as required, leading to a blockage and incomplete administration. This was against the prescribed orders and facility policy, posing a risk to the resident's condition.
A resident with a PEG tube received omeprazole in crushed pill form instead of the prescribed liquid suspension, leading to a blockage in the syringe during administration. The facility's policies and physician orders were not followed, posing a risk of PEG tube blockage and absorption issues.
The facility failed to securely store discontinued and destroyed medications, as observed in two medication rooms. Cabinets containing medications were found unlocked, and a biohazard bin with medications was easily accessible. The DON confirmed the lack of security, which contradicts the facility's policy requiring locked storage and limited access to authorized personnel.
The facility failed to implement action plans for an infection control issue as part of their QAPI program, affecting 108 residents. A PIP was initiated, but key tasks such as in-service training, competency checks, and weekly skin sweeps were not documented. Interviews revealed incomplete training and lack of required monthly reviews, contrary to the facility's QAPI policy.
The facility failed to maintain effective infection control, with personal items on the floor, improper PPE use for a resident on Enhanced Barrier Precautions, unlabeled urinals, unsanitized blood pressure cuffs, and soiled linens on the floor. These actions posed infection risks, contrary to the facility's policies.
A resident's room was found to be unsafe and unsanitary, with electrical devices improperly plugged into a power strip, oxygen tubing on the floor, and clutter creating a fire hazard. The room was also unclean, with a sticky substance on the floor identified as feces. These conditions violated the facility's policies on electrical safety and maintaining a homelike environment.
The facility failed to maintain resident rights when four staff members did not wear ID badges, affecting three residents. One resident with moderately impaired cognition and another with intact cognition expressed concerns about not knowing their caregivers due to the absence of ID badges. Observations confirmed that two LNs and two CNAs were not wearing badges, contrary to facility policy requiring ID badges for safety and security.
A resident with multiple medical conditions, including diabetes and osteomyelitis, did not receive prescribed MASD treatment on eight PM shifts. The treatment, which included cleansing and applying zinc oxide, was not documented as completed, contrary to physician's orders and facility policy. This lapse was confirmed by a nurse and acknowledged by the administrator.
A resident in the facility did not have a functional call system in the bathroom, despite having medical conditions that necessitate such a system. The issue was reported to maintenance months prior but remained unresolved. Staff interviews confirmed the absence of a call bell, contrary to facility policy and CMS guidelines.
A facility failed to notify a resident's representative about a room change, potentially causing distress. The resident, diagnosed with gangrene and Parkinson's Disease, was moved without informing the representative, who expressed concern. The DON and SSD confirmed the absence of documentation regarding the notification or reason for the room change, contrary to facility policy.
A resident with gangrene and Parkinson's Disease was neglected in terms of hygiene care, as the facility failed to provide scheduled showers. The resident's representative reported the resident appeared dirty and unkempt. The DON could not find documentation of showers being offered, received, or refused, contrary to facility policy requiring such records.
Failure to Prevent CNA Financial Exploitation of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a CNA solicited and obtained money and used the resident’s debit card for personal use. The resident was admitted with anxiety disorder, depression, and limitations of activities due to disability, and had an intact BIMS score of 14. The resident reported a sudden depletion of funds from her bank account after being informed by the bank that her balance was low and that her debit card may have been used inappropriately. Facility staff assisted the resident in reviewing recent bank transactions and identified multiple transactions associated with food delivery services, and text messages between the resident and the CNA showed repeated requests for money. Progress notes and interdisciplinary team documentation indicated that the resident verbalized feeling upset, concerned, and emotionally distressed after discovering the financial transactions. The resident reported difficulty recognizing appropriate financial boundaries with staff, expressed that her trust had been violated, and stated she did not want to see the staff member involved. Over several days, activity and nursing notes documented that the resident was emotional, upset, hurt, disappointed in herself and the CNA, and that she found it hard to understand why someone would do this, making it hard for her to trust others. The resident was noted to be mostly in her room, sleeping much of the day, socially withdrawn, and not interested in activities. Interviews and record review confirmed that the CNA had requested and received money and gifts from the resident multiple times, including ATM withdrawals using the resident’s debit card. Text messages reviewed with the resident showed the CNA requested money on multiple specific dates over several weeks. The resident stated she had allowed the CNA to use her card but had not given permission to take money to the extent that occurred, and she reported feeling pressured to give money and that she had never been told by the facility not to give money to staff. Facility staff, including a nurse, another CNA, social services, and the DON, stated that staff are trained and expected not to ask for or receive money or gifts from residents and that such conduct could constitute financial abuse or misappropriation of resident property. The facility’s abuse prevention policy stated residents have the right to be free from misappropriation of resident property and exploitation and that administration will protect residents from abuse by facility staff.
Failure to Provide Scheduled Showers and ADL Support
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically scheduled showers, for one resident. The resident was admitted in late winter 2026 with diagnoses including walking and mobility abnormalities, need for assistance with personal care, and heart failure. An MDS dated 1/26/26 showed the resident had no memory impairment and was totally dependent on staff for shower transfers. The resident’s ADL care plan, initiated 1/28/26, identified ADL self-care needs and risk for pressure injury and skin breakdown, with instructions that skin discoloration should be noted during baths. Review of shower documentation showed the facility could not produce a shower sheet for the week of 1/14/26, indicating the resident did not receive a shower that week, and subsequent weekly shower sheets dated 1/22/26, 1/26/26, and 2/2/26 each showed only one shower provided that week. Staff interviews confirmed that facility practice and expectation were for residents to receive showers twice weekly, with showers offered on either AM or PM shifts and refusals documented on shower sheets. A licensed nurse stated showers were expected two times per week and could be offered in the evening if a resident was unavailable due to appointments. A CNA reported that all residents were scheduled for baths twice per week, that no residents were scheduled once weekly unless they refused, and that refusals and skipped baths were reported to the nurse and documented. The ADON confirmed that shower sheets were used to document all showers and refusals, and that showers were scheduled twice weekly. In contrast, the resident and a family member reported that multiple showers had been missed, with the resident stating he sometimes skipped an entire week and only received one shower, and that he had not requested to receive only one shower per week. Facility policies on Abuse and Neglect and on ADLs required staff to institute measures to address residents’ needs to minimize neglect and to provide services necessary to maintain grooming and personal hygiene, which were not followed in this case.
Failure to Follow Contact Precautions for Resident on MRSA Isolation
Penalty
Summary
A deficiency occurred when a contracted phlebotomist failed to follow the facility’s contact precaution requirements while providing care to a resident with a documented Methicillin Resistant Staphylococcus Aureus (MRSA) sacral wound infection. The resident had a physician’s order dated 2/9/26 for contact precautions every shift, which required the use of gloves and a gown for all room interactions. During an observation and concurrent interview on 2/19/26 at 8:46 a.m., the contracted phlebotomist drew blood from this resident without wearing a gown. After leaving the room, the phlebotomist touched phlebotomy equipment without changing gloves or performing hand hygiene, then returned to the resident to continue the blood draw. When questioned, the contracted phlebotomist was unable to state what constituted contact precautions or whether a gown was required for direct care. After this interaction, the phlebotomist entered another resident’s room to draw blood without cleaning the equipment. The Infection Preventionist later confirmed that the resident was on contact precautions and that staff performing direct care, such as blood draws, should wear a gown. The DON stated that contact precautions should be followed by all staff, including contracted staff. The facility’s written policy on Isolation - Categories of Transmission-Based Precautions, revised 10/18, specified that staff and visitors will wear gloves and a disposable gown upon entering the room of a resident on contact precautions, change gloves after contact with infective material, remove gloves and perform hand hygiene before leaving the room, and remove the gown before leaving while avoiding contact of clothing with potentially contaminated surfaces.
Failure to Prevent Allergen Exposure During Meal Service
Penalty
Summary
A resident with a documented allergy to bananas, which causes anaphylaxis, was served Banana Cream Pie during a lunch meal. The resident's clinical record, nutritional assessment, and care plan all indicated a banana allergy, and the meal ticket for the day also noted this allergy. Despite these precautions, the resident received and consumed the dessert containing banana, which led to a severe allergic reaction. The incident required immediate medical intervention, including the administration of epinephrine, after the resident exhibited symptoms such as throat closing, shortness of breath, wheezing, agitation, and anxiety. Interviews with facility staff, including the Dietary Supervisor, Administrator, and Director of Nursing, confirmed that the expectation and policy are to prevent residents from being served foods to which they are allergic. The facility's kitchen documentation outlined responsibilities for cooks and dietary aides to ensure trays are correct and substitutions are made for allergies. However, the process failed, and staff were unable to explain how the resident was served the allergen. The facility's policy on food allergies emphasized steps to prevent exposure, but these were not effectively implemented in this case.
Failure to Assist Resident with Dentures Prior to Meals
Penalty
Summary
The facility failed to provide necessary assistance with the use of dentures for one resident who was cognitively intact but had significant upper extremity impairment and required substantial or maximal assistance for oral hygiene, including inserting and removing dentures. The resident's care plan identified a self-care performance deficit and risk for decline in activities of daily living due to generalized weakness, carpal tunnel syndrome, and macular degeneration. The nutritional assessment confirmed the resident had dentures. On the morning of the observed incident, the resident was found in bed without dentures and stated that no one had assisted her with them that morning, despite requesting help from staff around 8:30 a.m. The denture cup was observed on the dresser, unused. A CNA who assisted the resident with breakfast reported not noticing the absence of dentures and was unaware the resident had them. The DON confirmed the importance of offering dentures to the resident, acknowledging that without them, the resident would be unable to chew food. The facility's policy required staff to provide appropriate support and assistance with activities of daily living, including dining, for residents unable to perform these tasks independently and in accordance with the care plan.
Unlabeled Medication Cups Left at Bedside
Penalty
Summary
A deficiency occurred when three unlabeled medication cups containing white cream were found inside a white plastic container on top of a resident's dresser. The resident, who was cognitively intact and had a diagnosis including generalized muscle weakness, stated that the cups contained lidocaine cream brought in by a nurse and that it was applied to her hands twice daily. Multiple staff members, including two CNAs and a treatment nurse, confirmed the presence of the unlabeled cups and noted that the cream should not have been left at the bedside, especially without proper labeling. One CNA expressed concern that a confused resident might mistakenly ingest the cream, and the treatment nurse indicated the cream resembled barrier cream. The Director of Nursing, upon being shown a picture of the cream, acknowledged that it was unacceptable for licensed staff to leave creams or unknown substances at the bedside. A review of the facility's policy confirmed that drugs and biologicals are to be stored in locked compartments. The failure to properly label and securely store the medication at the resident's bedside constituted a breach of the facility's medication storage policy.
Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis following cerebral infarction, and dysphagia, was left unsupervised in his room despite being care planned for one-to-one supervision due to high risk for falls and elopement. The resident had severely impaired cognition and a documented history of falls, with a Morse Fall Assessment score indicating high risk. During observation, the resident was found sitting on the edge of his bed with his call light on the floor and no staff or sitter present, despite requiring assistance with meals and supervision at all times. Staff interviews confirmed that the resident should have had continuous one-to-one supervision, and the assigned sitter was observed exiting the resident's bathroom, leaving the resident unattended. The care plan and staff training records indicated that the expectation was for the resident to never be left unattended, and the DON confirmed that staff are expected to arrange relief if a sitter needs a break. The facility was unable to provide a specific policy for sitter or supervision when requested.
Failure to Maintain Fully Functional Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was fully functional and properly maintained for one resident. When the resident pressed the call light button, the call light above the room door activated, but the corridor call lights located on the wall and above the double door did not illuminate. This incomplete functionality was confirmed through observations, interviews with staff, and review of records. The resident, who was cognitively intact and capable of making health decisions, expressed ongoing concerns about delayed staff response to call lights. Staff interviews confirmed that the corridor call lights did not illuminate when the resident activated the call light, making it difficult for staff to know when assistance was needed unless they were physically near the room. Further investigation revealed that the call light system had not been reprogrammed after servicing, and the issue had not been reported to maintenance or facility leadership. The maintenance request log and call light maintenance log were not provided for review. Staff, including CNAs and the Assistant Maintenance Supervisor, acknowledged the importance of the corridor call lights for timely response and resident safety. The facility's policy required immediate notification and repair of malfunctioning call lights, but the Director of Nursing and other leadership were unaware of the issue until it was brought to their attention during the survey.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive and communication deficits, who was incapable of making her own healthcare decisions, was physically abused by another resident with a history of bipolar disorder and aggression. The incident involved the aggressive resident striking the vulnerable resident on the left side of her forehead with a closed fist, resulting in a visible bruise and a hematoma. The assaulted resident exhibited fear and distress, manifested by crying and avoidance behaviors, particularly when the aggressor was present in the room. Prior to the incident, the aggressive resident had documented daily physical behavioral symptoms directed towards others, including verbal and physical aggression. The care plan for this resident noted a history of uncontrolled anger and poor impulse control, with instructions to assess and anticipate needs and to immediately separate parties involved in confrontations. Despite these documented risks and interventions, the aggressive resident was able to physically assault her roommate, indicating a failure to prevent abuse as outlined in the facility's abuse prevention policy. Multiple staff interviews confirmed the aggressive behaviors, including yelling, cursing, and physical threats towards both residents and staff. The assaulted resident was unable to verbally express herself due to her medical condition but demonstrated fear through nonverbal cues and crying. Staff, including the DON, Social Services Director, and an LPN, all acknowledged the abusive behavior and its impact on the assaulted resident, confirming that the facility did not ensure the resident's right to be free from abuse.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one with violent behavior, restlessness, and agitation, and another with dementia. According to the nurse's notes, one resident was observed striking and being verbally abusive to their roommate, as well as taking items from the roommate's closet. The incident escalated to physical aggression, including kicking and slapping, as witnessed by a licensed nurse. The nurse reported the incident to the direct supervisor but was not instructed to complete the required SOC341 form for suspected dependent adult/elder abuse. During interviews, the licensed nurse confirmed the incident was not reported to the state, and the administrator stated that all cases of abuse, even those between residents with dementia and without injury, should be reported to law enforcement, the ombudsman, and the California Department of Public Health within two hours. A review of the facility's policy indicated that all allegations must be investigated and reported within federally required timeframes. The failure to report this incident constituted a deficiency in mandated reporting procedures.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
CNA Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that nursing care staff met certification requirements as defined under State law and regulation. Specifically, one certified nursing assistant (CNA) was scheduled to work with an expired CNA certification. A review of the CNA's employee file confirmed that the certification had expired, and the CNA continued to work after the expiration date. The Director of Staff Development (DSD) acknowledged during an interview that the certification was not renewed and admitted to the oversight. The DSD recognized the potential impact of this lapse, stating that it could affect everyone and that someone could be harmed. Further interviews revealed that the Director of Nursing (DON) expected the DSD to maintain a tracker or spreadsheet to monitor certification expiration dates and ensure timely renewal before staff are scheduled to work. A review of the relevant Health and Safety Code confirmed that certified nurse assistants are required to be certified to perform basic patient care services. The failure to ensure current certification for the CNA meant that the facility did not comply with professional standards of practice for staffing.
Failure to Offer and Document COVID-19 Vaccination for Resident and Staff
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered and properly documented for both residents and staff, as evidenced by the lack of vaccination status or documentation for one resident and one staff member. Specifically, a resident admitted with cerebral palsy and severe cognitive impairment had no record of being offered the COVID-19 vaccine, no documentation of vaccination, refusal, or contraindication, and no evidence that the required education or consent process occurred. The resident's care plan indicated COVID-19 isolation precautions following a positive test, but the clinical record did not reflect any action regarding vaccination upon admission. The Infection Preventionist confirmed that there was no monitoring system in place for resident COVID-19 vaccinations and acknowledged the omission. Similarly, a certified nursing assistant's employee health file lacked any documentation of COVID-19 vaccination status, offer, or refusal. Interviews with the Infection Preventionist, Director of Staff Development, and Director of Nursing confirmed that the facility's expectation was to offer and document COVID-19 vaccination for all staff upon hire and annually, but this was not done for the staff member in question. Review of facility policies indicated requirements for offering and documenting COVID-19 vaccination for both residents and staff, but these procedures were not followed in the cited cases.
Failure to Follow Physician Orders for Scabies Treatment and Prophylaxis
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for three residents regarding the administration of medications for scabies treatment and prophylaxis. For one resident with schizophrenia and moderate cognitive impairment, the prescribed Permethrin cream was not administered as ordered, and an order for oral Ivermectin was not carried out. The Assistant Director of Nursing (ADON) confirmed that the medication was not signed off in the Medication Administration Record (MAR) and that there was no evidence the treatment was given, despite a physician's order. Another resident with Adult Failure to Thrive and dementia, also with moderate cognitive impairment, received Permethrin cream on two consecutive days instead of the single application as ordered. The MAR showed that staff entered and signed off on two separate orders, resulting in back-to-back administration. The ADON acknowledged this deviation from the order and noted the potential for side effects due to excessive use, confirming that the physician's instructions were not followed. A third resident with severe cognitive impairment and dementia did not receive Permethrin cream in a timely manner. Although the order was received, the medication was administered two days later without documentation explaining the delay. The ADON verified that there was no note or notification to the physician regarding the delay, and facility policy requires medications to be administered according to prescriber orders and within required time frames.
Failure to Maintain Contact Precautions and Administer Scabies Treatment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was suspected of having scabies. The resident was admitted with multiple diagnoses, including schizophrenia and moderate cognitive impairment, and developed a non-improving rash with itching. Physician orders and facility policy required the resident to be placed on contact isolation and to receive Permethrin cream treatment for scabies, with isolation to continue for 24 hours after treatment. However, the resident's contact precaution signage was removed before the resident received the prescribed treatment, and the medication administration record showed that the Permethrin cream was not administered as ordered. Observations confirmed that the resident still had visible rashes and was no longer on contact precautions, despite not having received the required treatment. Interviews with facility staff, including the Infection Preventionist and Assistant Director of Nursing, verified that the resident should have remained on contact isolation until after treatment was completed, in accordance with facility policy. The failure to administer the prescribed treatment and to maintain contact precautions as required constituted a breakdown in the facility's infection prevention and control practices.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit her on the left hand, resulting in a bruise. The incident occurred when the second resident, who was severely cognitively impaired, entered the first resident's room, which was previously her own room. The first resident attempted to push the second resident's wheelchair out of the room, leading to the second resident striking her on the hand. The first resident was admitted to the facility with multiple diagnoses, including a stage 4 pressure ulcer, dementia, and diabetes, and was cognitively intact with a BIMS score of 14 out of 15. The second resident, admitted with metabolic encephalopathy, Horner's syndrome, and dementia, had a BIMS score of 4, indicating severe cognitive impairment. The second resident had a history of aggressive behavior, including striking staff during care, and was on psychotropic medications for these behaviors. Interviews with staff and the residents revealed that the second resident had been following the first resident and had previously been moved to a different room due to incompatibility. The facility's policies on abuse prevention and resident-to-resident altercations were reviewed, indicating that residents should be protected from abuse and that all altercations should be investigated. However, the facility failed to prevent the altercation and protect the first resident from being struck.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident who was admitted with a skin infection and had an indwelling Foley catheter. The resident's care plan included Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs). According to the facility's policy, staff were required to wear gowns and gloves during high-contact activities, such as changing briefs or assisting with toileting, for residents on EBP. During an observation, a Certified Nursing Assistant (CNA) was seen changing the resident's soiled brief without wearing a protective gown, which was a violation of the facility's infection control policy. The CNA acknowledged the requirement to wear a gown to prevent the spread of bodily fluids. The Infection Preventionist confirmed that staff should wear gowns during high-contact care for residents on EBP due to the increased risk of spreading MDROs.
Food Safety Violations in LTC Facility
Penalty
Summary
The facility failed to maintain food safety standards in several areas, leading to potential food contamination risks for all 105 residents. The ice machine was found to be unclean, with white and pink slimy substances and black deposits, indicating inadequate cleaning and maintenance. The Environmental Services Manager admitted to sometimes delegating the cleaning to an outside vendor, who confirmed the presence of hard deposits that could harbor bacteria. The Registered Dietician expected the ice machine to be cleaned per manufacturer's guidelines, but the facility's policy was not followed. Additionally, kitchenware was improperly stored while still wet, and fry pans were found with black flaky debris, indicating they were not clean. The Dietary Supervisor acknowledged the need for air drying and the disposal of old pans. Open food packages were not sealed or labeled correctly, and expired food items were found in storage, posing a risk of contamination. The Registered Dietician emphasized the importance of proper labeling and disposal of expired products, but the facility's policies were not adhered to. Thawing processes were not followed, with food items lacking proper labeling and being stored inappropriately, leading to potential cross-contamination. Dietary staff also failed to demonstrate knowledge of correct dishwashing procedures, including sanitizer concentration testing. Furthermore, a dietary staff member did not have their hair fully covered, violating the facility's dress code. These deficiencies highlight significant lapses in food safety practices, which could lead to foodborne illnesses among the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in multiple instances where the lids of two outside dumpsters were not adequately closed, and the surrounding area was littered with debris. During an observation with the Dietary Supervisor, it was noted that the lid of a garbage dumpster containing trash bags was not tightly closed, and a urinal with brown and yellow liquid was found on the ground next to the garbage bin. The Dietary Supervisor confirmed that the lid was open and should have been tightly closed. Subsequent observations revealed that the gate to the dumpster area was open, and the hatch doors on both the garbage and recycling dumpsters were open. Further observations with the Environmental Services Manager confirmed that the lids of the dumpsters were open, and there was scattered trash around the area. The Environmental Services Manager acknowledged that the area was dirtier than desired and confirmed that the area around the dumpsters should be kept clean. An interview with the Registered Dietitian reiterated the need for the garbage bin lids to be closed at all times and the surrounding area to be kept clean to prevent pests and rodents. The facility's policy and procedure on sanitation indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area, and that the lids are closed, as the trash collection area is a potential feeding ground for vermin and rodents.
Dietary Services Supervisor Lacks Competency in Food Safety Procedures
Penalty
Summary
The Dietary Services Supervisor (DS) at the facility failed to demonstrate the necessary competencies and oversight required for the food and nutrition services, which could potentially lead to foodborne illness among the residents. During an observation, it was noted that the DS was unable to verbalize the proper procedure for thawing meats using the refrigeration method. Additionally, the DS did not have proper knowledge about the correct concentration of the sanitizer for the dishwashing machine and the manual dishwashing process using a three-compartment sink. Furthermore, the DS did not have his hair fully covered by a hair restraint while in the kitchen. During an inspection of the walk-in refrigerator, it was observed that there were three-level carts with boxes of food, some of which were wet and leaking. The DS confirmed that these items were for thawing but could not determine when they were pulled from the freezer due to the absence of dates. The facility's policy requires thawing meat in a refrigerator with proper labeling and separation to prevent cross-contamination, which was not adhered to. Additionally, the DS was unable to verify the correct concentration of the sanitizer for both the dishwashing machine and the manual dishwashing process, as per the facility's policy. The DS's employee file revealed that his ServSafe certification had expired, and his last performance evaluation was conducted by a previous administrator. The facility administrator acknowledged the issues found in the kitchen and planned to address them under the Quality Assurance and Performance Improvement (QAPI) program. The facility's job description for the DS includes responsibilities such as ensuring compliance with dietary procedures and conducting in-service training, which were not effectively carried out as evidenced by the deficiencies observed.
Inadequate Competency in Dietary Aide Poses Risk
Penalty
Summary
The facility failed to ensure that a Dietary Aide (DA 1) possessed the necessary skills to safely perform food and nutrition services. During an observation and interview, DA 1 demonstrated an incorrect understanding of the dishwashing process using a dishwashing machine. DA 1 incorrectly stated that the sanitizer concentration should be 200 ppm, while the facility's policy indicated it should be between 50-100 ppm. DA 1 also used a used test strip to check the sanitizer concentration, which showed no color, and only after being instructed by the Dietary Services Supervisor (DS) did DA 1 use a new test strip, which read 50 ppm. This was within the correct range, but DA 1's initial misunderstanding and incorrect demonstration highlighted a lack of competency. Additionally, DA 1 was unable to correctly verbalize the manual dishwashing process using a three-compartment sink. DA 1 stated that the sanitizer immersion time was 10 seconds with a concentration of 50 ppm, which was incorrect according to the facility's policy and the sanitizer bottle instructions, which required a 60-second immersion time and a concentration of 150-400 ppm. Despite having attended in-service training and holding a valid ServSafe food handler certificate, DA 1's inability to correctly demonstrate and verbalize these processes posed a risk to the 105 out of 108 highly susceptible residents who consumed food from the facility.
Menu Non-Compliance in Dietary Service
Penalty
Summary
The facility failed to adhere to the planned menu for lunch on November 6, 2024, resulting in several dietary discrepancies. Two residents on large portion diets received five meatballs instead of the prescribed six, as observed by the Registered Dietitian (RD) during meal service. The facility's menu indicated that a large portion should consist of six meatballs, but the cook provided only five, which the RD acknowledged as insufficient for residents requiring extra protein. Additionally, four residents on renal or CKD5 diets were served tapioca pudding instead of the specified cookie. The facility's diet manual for renal diets restricts protein and phosphorus intake, recommending cookies over puddings. The RD confirmed that the menu was not followed, potentially impacting the dietary management of these residents' kidney conditions. Further discrepancies were noted for residents on low fat and low cholesterol diets, who received whole milk and margarine instead of fat-free milk and no margarine. Residents on finger food diets were served rice and tapioca pudding, contrary to the menu's specification of diced potatoes and mousse on graham crackers. Moreover, none of the 105 residents received the parsley garnish as indicated on the menu. These failures were acknowledged by the RD and Dietary Supervisor, who confirmed that the menu was not followed during the tray line meal service.
Failure to Adhere to Medication and Oxygen Administration Policies
Penalty
Summary
The facility failed to meet professional standards of quality care for two residents. For Resident 11, medications were left unattended on the bedside table, contrary to the facility's policy. Resident 11, who was admitted with acute and chronic respiratory hypoxia and Type 2 Diabetes with polyneuropathy, reported that nurses routinely left medications for self-administration without supervision. Interviews with the Licensed Nurse, Assistant Director of Nursing, and Director of Nursing confirmed that this practice was against facility policy, which requires a Medication Administration Assessment and documentation in the care plan for self-administration. However, no such assessment or care plan documentation was found for Resident 11. For Resident 5, the oxygen tubing was found unconnected to the oxygen machine, resulting in the resident not receiving oxygen as prescribed. Resident 5, who had chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed to be pale and breathing rapidly. The Licensed Nurse confirmed the disconnection and noted the resident's oxygen level was at 82 percent, below the prescribed level. The facility's policy requires medications and treatments to be administered safely and as prescribed, which was not adhered to in this case.
Lack of Smoking Policy and Supervision in Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for its residents, specifically in relation to smoking policies and supervision. Two residents, one with asthma and nicotine dependence and another with COPD and nicotine dependence, were observed smoking unsupervised on the facility premises. The facility did not have a smoking policy and procedure in place, and the Assistant Director of Nursing (ADON) acknowledged the absence of such policies despite being aware that some residents smoked. This lack of policy and supervision posed potential risks for accidents, including resident injury and fire. Additionally, the facility did not have a smoking care plan for a resident who was non-compliant with care and safety recommendations. The resident's smoking assessment indicated the need for a care plan to ensure safety while smoking, including supervision. However, the care plan did not address smoking or interventions for safety. The ADON confirmed the absence of a care plan for smoking and acknowledged the associated risks. The facility also failed to provide a policy and procedure for care planning when requested.
Medication Administration Errors via PEG Tube
Penalty
Summary
The facility was found to have a 20.69% medication error rate during a medication pass for one resident, significantly exceeding the acceptable threshold of 5%. During the observation, a licensed nurse prepared and administered medications to a resident with a PEG tube without following the prescribed orders. The nurse crushed and combined multiple medications, including omeprazole, aspirin, and Cardizem, and administered them through the PEG tube without flushing it before and after each medication. This resulted in large particles of omeprazole blocking the syringe, preventing the complete administration of the medication. The nurse acknowledged the error and the risk of blockage and air entering the PEG tube due to improper crushing and administration of medications. The resident's medical record indicated specific physician orders for the administration of each medication, including the requirement to flush the feeding tube with water before and after each medication. The facility's policy and procedure for administering medications through an enteral tube also emphasized the need to administer each medication separately and to flush between medications. The failure to adhere to these protocols resulted in a medication error, with the potential to affect the resident's clinical condition. The Assistant Director of Nursing confirmed the expectation for adherence to physician orders and acknowledged the risks associated with improper medication administration.
Medication Error with PEG Tube Administration
Penalty
Summary
The facility failed to ensure that Resident 88 was free from significant medication errors when he received omeprazole in crushed pill form instead of the physician-ordered liquid suspension through his PEG tube. Resident 88, who was admitted with multiple diagnoses including cerebral infarction and GERD, had a care plan indicating the use of a PEG tube. During a medication pass, a licensed nurse crushed omeprazole along with other medications and administered them through the PEG tube, resulting in large particles of omeprazole blocking the syringe and preventing full administration. The physician's orders specified the use of omeprazole oral suspension, and there were no orders allowing substitution with a delayed-release tablet. The facility's policy and procedure documents also indicated that enteric-coated and sustained-release medications should not be crushed. The Assistant Director of Nursing confirmed that the expectation is to follow physician orders and that incorrect administration poses a risk of PEG tube blockage and absorption issues.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store discontinued and destroyed medications in locked compartments, as required by professional principles and the facility's own policy. During an observation and interview with a licensed nurse, it was found that a cabinet in the medication room was unlocked and contained multiple packets of medications, bottles of pills, and liquid medications. The nurse confirmed that the cabinet was kept unlocked. Additionally, another cabinet with double doors was also found unlocked, containing approximately 160 packets of medications and bottles of liquid medications. Further observations revealed that a large blue Medi Waste Disposal Biohazard bin in the medication room was unsecured and easily accessible, containing multiple pills, bottles, and liquid medications. The Director of Nursing confirmed that the discontinued medications and the biohazard bin were not secured, allowing staff access to these medications. The facility's policy and procedure on medication storage, revised in November 2020, indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner, with access limited to authorized personnel.
Failure to Implement Infection Control Action Plans
Penalty
Summary
The facility failed to implement action plans in their Quality Assurance and Performance Improvement (QAPI) program for an identified infection control issue affecting a census of 108 residents. A Performance Improvement Project (PIP) was initiated on 8/16/24 to address this issue, with review dates set for 9/16/24, 10/16/24, and a planned completion date of 11/16/24. However, there was no documented evidence that key tasks were completed, including in-service training for the nursing department, 100% competency skills checks for current and new staff, and weekly skin sweeps. Additionally, findings from these audits were not reported in the Quality Assessment and Assurance (QAA) monthly meetings as required. Interviews with the Infection Preventionist (IP) and the Administrator (ADM) revealed that some training was completed, but there was no documentation to support the completion of the required competency skills checks or weekly skin sweeps. The ADM confirmed that no monthly meetings or reviews were conducted in September or October 2024, as stipulated in the PIP. The facility's policy and procedure for the QAPI program, dated February 2020, mandates monthly committee meetings to review reports, evaluate data, and monitor QAPI-related activities, which were not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Personal items belonging to a resident were found on the floor, which the resident expressed dissatisfaction with, and staff acknowledged as an infection control risk. Additionally, staff failed to wear the required personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions, despite the presence of a sign indicating the need for gown and glove use. Further deficiencies were noted with the improper labeling and storage of urinals for two residents, which posed a risk of cross-contamination. The urinals were not labeled with resident identifiers or dates of initial use, and there was no documented evidence that the residents used urinals for incontinence. Additionally, a blood pressure cuff was not sanitized between uses on different residents, which was acknowledged by the staff as a risk for spreading infection. Lastly, linens and a soiled incontinence pad were observed on the floor of a resident's room, which the resident admitted to discarding. Staff interviews confirmed that such practices were not acceptable and posed an infection control issue. The facility's policies and procedures emphasized maintaining a safe and sanitary environment, which was not adhered to in these instances.
Unsafe and Unsanitary Conditions in Resident's Room
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, identified as Resident 66, who was admitted with multiple diagnoses including obstructive sleep apnea, acute respiratory failure, and a history of falling. During an observation, it was noted that electrical devices such as a CPAP machine, a personal fan, and a laptop were plugged into a power strip located under the bed, surrounded by loose electrical cords and other items, creating a fire hazard. The power strip was used with medical devices, which is against the facility's policy. Additionally, oxygen tubing was found lying on the floor, further contributing to the unsafe environment. The room was also found to be unsanitary, with unclean floors and clutter that made cleaning difficult, increasing the risk of bacterial growth and infection. A dark, sticky substance was observed on the floor, which the resident identified as feces that had been present for several days. The facility's policies on electrical safety and maintaining a homelike environment were not adhered to, as evidenced by the clutter and unsanitary conditions in the resident's room. These deficiencies had the potential to cause preventable falls and unsafe living conditions for the resident.
Failure to Wear ID Badges Compromises Resident Rights
Penalty
Summary
The facility failed to ensure the rights of residents were maintained when four employees did not wear identification badges, affecting three of six sampled residents. Resident 2, who was admitted in October 2024 with diagnoses including leg ulcers, heart failure, and muscle weakness, had a BIMS score indicating moderately impaired cognition. During an interview, Resident 2 expressed not knowing his nurse or CNA due to the absence of ID badges. Similarly, Resident 5, admitted in September 2024 with conditions such as stimulant dependence and bipolar disorder, also had a moderately impaired cognition and voiced concerns about not knowing the names of the staff attending to her. Resident 6, with intact cognition, shared similar concerns about not being able to identify her caregivers. Observations confirmed that several staff members, including two LNs and two CNAs, were not wearing ID badges while on duty. LN 2, CNA 5, CNA 6, and LN 3 all admitted to not wearing their badges, citing reasons such as forgetting them or leaving them in personal belongings. The facility's policy, revised in January 2008, mandates that all employees wear identification badges to promote safety and security. The administrator acknowledged the importance of this policy, emphasizing that it is crucial for residents to identify the staff caring for them.
Failure to Administer MASD Treatment as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and its own policies for one resident. The resident, who was admitted in October 2024, had several medical conditions including osteomyelitis of the vertebra, diabetes mellitus, muscle weakness, and severe obesity. The resident was at risk for developing pressure ulcers and had moisture-associated skin damage (MASD). A physician's order was in place for the treatment of MASD, which included cleansing the affected area with normal saline, patting it dry, applying zinc oxide every shift, and monitoring for any signs of infection or skin breakdown. However, the Treatment Administration Record (TAR) indicated that the MASD treatment was not administered on eight PM shifts throughout October 2024. This was confirmed by a licensed nurse who acknowledged the lack of documentation for the treatment on those shifts. The facility's policy and procedure, as well as CMS guidelines, require that wound care be performed according to accepted medical standards, which was not adhered to in this case. The administrator also confirmed that physician's orders for treatments should be followed.
Deficiency in Resident Call System in Bathroom
Penalty
Summary
The facility failed to provide a functional resident call system in the bathroom for one of the residents, identified as Resident 7. This deficiency was identified through observation, interview, and record review. Resident 7, who was admitted in October 2024, had medical conditions including atrial fibrillation, major depressive disorder, and muscle weakness. Despite being capable of making her own health decisions, Resident 7 did not have a working call system in her bathroom, which was confirmed during an observation on October 28, 2024. The call light in Resident 7's room was noted to be constantly on and broken, a situation that had been reported to maintenance as early as May 7, 2024, but remained unresolved. Interviews with various staff members, including a Licensed Nurse, the Director of Environmental Services, a Certified Nurse Assistant, and the Administrator, confirmed the absence of a functional call system in Resident 7's bathroom. Although the Director of Environmental Services mentioned that a call bell was provided to the resident, Resident 7 and the Certified Nurse Assistant confirmed that no such bell was present in the bathroom or at the bedside. The facility's policy requires a resident call system to be available, and the Centers for Medicare & Medicaid Services guidelines mandate that the call system must be accessible from each toilet, bath, or shower. The lack of a functional call system in Resident 7's bathroom was a clear violation of these guidelines and policies.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify the representative of a resident regarding a room change, which had the potential to cause psychosocial distress to the resident and concern to the representative due to the lack of notification. The resident, who was admitted in mid-2024 with diagnoses including gangrene and Parkinson's Disease, was moved to another room without informing the representative. During a phone interview, the representative expressed upset and concern over not being informed or given a reason for the room change. The Director of Nursing and the Staff Services Director both confirmed that there was no documentation in the resident's chart indicating the reason for the room change or that the representative was notified. The facility's policy requires that family and visitors be informed of room changes and that such information be recorded in the resident's medical record.
Neglect in Resident Hygiene Care
Penalty
Summary
The facility failed to protect a resident from neglect by not providing showers as scheduled. The resident, who was admitted with diagnoses including gangrene and Parkinson's Disease, was observed by their representative to appear dirty, with messy hair covered in food, resembling a homeless person. During a review of the resident's bathing tasks and shower sheets, the Director of Nursing (DON) could not find documentation that the resident had been offered, received, or refused a shower during a specific period. The facility's policy required documentation of the date and time of showers or reasons for refusal, but this was not adhered to, leading to uncertainty about whether the resident received proper hygiene care.
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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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