River Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Live Oak, California.
- Location
- 9000 Larkin Road, Live Oak, California 95953
- CMS Provider Number
- 555535
- Inspections on file
- 29
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at River Valley Care Center during CMS and state inspections, most recent first.
Staff failed to use appropriate, resident-specific pain assessment tools for a resident with cognitive impairment, instead relying solely on the 0-10 numerical pain scale even when the resident could not verbalize pain levels. Despite policy requiring alternative assessment methods and descriptive documentation, staff assigned pain scores based on facial expressions and did not consistently reassess pain after medication administration. Facility leadership confirmed that pain assessment policy was not followed.
Surveyors identified multiple deficiencies in kitchen food safety and sanitation, including improper dishwasher sanitization, use of expired test strips, lack of clear manual dishwashing procedures, a malfunctioning handwashing sink, expired and undated food items, improper storage of dirty dishes, and failure to cover or date thickener and thickened milk, all contrary to facility policy.
Surveyors found that several rooms in the locked unit were undecorated, lacked personalization, and had persistent foul odors. Bathrooms had broken or taped fixtures, and multiple areas showed peeling or patchy paint. The only outdoor courtyard was in poor condition, with uneven pavement, dead plants, and no shade. Staff interviews confirmed awareness of these issues, which did not meet facility policy for a homelike environment.
The facility was found to have a medication error rate of 35.7%, significantly above the acceptable threshold, due to multiple failures by nursing staff to follow medication administration policies and physician orders. These included improper documentation of a resident's medication refusal, failure to crush medications as ordered, not checking expiration dates, incorrect dosing of vitamin C, and improper administration of a corticosteroid inhaler without following manufacturer instructions. Staff interviews confirmed lack of adherence to required procedures and insufficient knowledge of medication administration protocols.
Surveyors found that medications, including nicotine patches, D-Mannose, and Restasis vials, were not labeled with resident names or expiration dates in two medication carts. In addition, a medication room was observed to be disorganized, with syringes, IV supplies, and wound care items scattered in unlabeled boxes, and a resident's heart monitor stored under the sink with cleaning supplies. Nursing staff and the unit manager confirmed these deficiencies and acknowledged that proper labeling and organization were not maintained.
A resident with dysphagia and other complex medical needs did not receive the prescribed all-pureed diet for over a month due to a communication lapse between staff, resulting in her continuing to receive a discontinued diet. The resident was observed struggling to eat independently, and the RD confirmed the error after being notified.
The facility did not report a COVID outbreak to the state health department as required by policy, and a CNA failed to follow hand hygiene protocols while providing incontinence care to a resident with multiple medical conditions, including not changing gloves or performing hand hygiene between soiled and clean tasks.
Several residents with significant care needs were provided with hand bells instead of functioning call lights after their call light cords broke. Staff and maintenance interviews confirmed that the bells could not be heard from other rooms or the nurse's station, and maintenance logs showed delays in repairing or replacing the call light cords. This resulted in residents' requests for assistance not being promptly addressed, despite care plans requiring accessible and working call systems.
A resident with Alzheimer's, dementia, visual impairment, and dysphagia was not accurately assessed for eating assistance needs, as the MDS indicated partial to moderate help was needed while the care plan required extensive assistance. Staff confirmed this inconsistency, and observations showed the resident sometimes ate independently but also needed significant help.
A resident admitted with acute respiratory failure, heart failure, pneumonia, and COPD was observed receiving continuous oxygen and having difficulty breathing, but the baseline care plan did not include any respiratory goals or interventions. The DON confirmed the omission, despite physician orders for oxygen therapy and facility policy requiring a baseline care plan within 48 hours of admission.
A resident with severe cognitive impairment and total dependence for ADLs was not provided with a care plan specifying the need for two staff members to assist with turning, bathing, and changing briefs. Despite assessment data indicating this requirement, the care plan lacked details on the number of helpers needed, and staff were observed providing care alone and unaware of the resident's needs.
A resident with advanced dementia, visual impairment, and contractures, who was care planned for extensive assistance with meals, was observed eating pureed food with her hands and left without help for an extended period. Staff only intervened after about ten minutes, despite the care plan requiring one-on-one feeding assistance.
A resident with multiple comorbidities and total dependence on staff was admitted with a red area on her sacrum, but the facility failed to measure, evaluate, or document the progression of this skin condition for three weeks. Despite daily treatments, staff did not record changes or provide follow-up assessments, and weekly skin checks inaccurately reported the skin as clear and intact.
A resident with dementia and psychotic disturbance was found with nine disposable razors and a pair of tweezers in her room, despite staff awareness of some hazardous items and facility policy requiring supervision and hazard prevention. Staff discomfort with the resident's combative behavior contributed to inadequate monitoring, resulting in the resident retaining access to items that posed a safety risk.
Three dietary aides responsible for dishwashing were not competent in using the three-compartment sink procedure, as evidenced by improper sanitizer testing with expired test strips, failure to initiate manual dishwashing when the dishwasher sanitizer was inadequate, and lack of knowledge about required dwell times for sanitization. These actions placed all residents at risk for cross contamination and food-borne illness.
The Medical Director did not adequately supervise or coordinate the response to a scabies outbreak that affected 31 residents over six months. Despite being responsible for infection control oversight, the MD was unaware of the outbreak's scope, did not track cases, and infection control meetings lacked detailed discussion or resolution. Residents received various treatments, but inconsistent documentation and incomplete follow-up contributed to the prolonged outbreak.
The facility did not maintain an effective QAPI program in response to two scabies outbreaks, as required by policy. Incomplete outbreak tracking, missing documentation on treatment and recovery, and insufficient meeting records led to inadequate identification and implementation of performance improvement activities. Leadership confirmed the lack of proper tracking and evaluation, resulting in multiple residents and all staff, vendors, and visitors being at risk for scabies exposure.
A resident with severe cognitive impairment and multiple health conditions experienced ongoing skin issues during a facility-wide scabies outbreak. Staff failed to follow best practices for scabies diagnosis and treatment, including untrained nurses performing unauthorized skin scrapings and inconsistent administration of recommended permethrin treatments. Delays in obtaining dermatology consultation and confirming the diagnosis contributed to prolonged symptoms and inadequate infection control.
A scabies outbreak affected 31 residents and a staff member due to incomplete surveillance, lack of infection control committee oversight, delayed and undocumented cleaning protocols, and delayed staff education. Two residents with severe cognitive impairment experienced delayed diagnosis and inconsistent management, with essential outbreak tracking information missing and the medical director unaware of the outbreak's full scope.
The facility failed to ensure bed safety by not locking wheels, risking resident falls. A resident with a hip fracture attempted to get out of bed, causing it to move due to unlocked wheels, resulting in an accident. Observations showed other residents' beds also had unlocked wheels, posing a fall risk during transfers. Staff interviews revealed no specific bed safety policy, with CNAs expected to lock wheels, contributing to the deficiency.
A resident, who was cognitively intact and continent, was made to wear an incontinent brief and not assisted to the bathroom for seven days, despite having a discharge order for weight bearing as tolerated. This oversight in the care plan led to the resident's frustration and was confirmed by staff interviews.
A resident's care plan was incomplete, lacking restrictions for the right arm post-mastectomy, weight-bearing instructions after hip surgery, and monitoring of surgical incision sites. These omissions were confirmed by staff, potentially impacting the resident's care and recovery.
A resident remained in bed for seven days post-hip surgery due to the nursing staff's failure to follow discharge orders allowing weight-bearing as tolerated. Despite being cognitively intact and capable of decision-making, the resident's requests to get out of bed were not honored, leading to potential emotional and clinical consequences. The oversight was confirmed by a nurse who admitted the care plan did not reflect the resident's mobility needs.
A resident with multiple health conditions, including a hip fracture and Parkinson's disease, required substantial assistance with ADLs. However, the facility failed to document care provided on several occasions, including bathing, mobility, incontinence, and food intake. This lack of documentation was confirmed by an LPN and the administrator, highlighting a deficiency in maintaining accurate medical records.
A resident with multiple health conditions, including congestive heart failure and COPD, experienced a change in condition but the facility failed to notify the physician in a timely manner. Despite the resident's refusal for hospital transport and lab work, staff did not follow up on the phlebotomist's report of the resident's compromised state. The resident was later found unresponsive, highlighting a breakdown in communication and adherence to facility policy.
A resident with multiple health conditions was discharged without proper planning, lacking a 30-day notice and physician order. The facility's social services department failed to document the discharge plan, leading to potential unsafe discharge and resident anxiety. Staff interviews revealed communication and coordination issues in the discharge process.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in documenting behaviors such as wandering and rejection of care. Despite staff observations and elopement risk assessments indicating these behaviors, they were not reflected in the MDS due to reliance on incomplete documentation. The SSA and SSD did not consider elopement assessments, resulting in inaccurate MDS coding.
A resident with severe cognitive impairment and a history of wandering was not effectively managed according to their care plan, leading to incidents of entering other residents' rooms and lying on their beds. Despite the care plan's interventions, staff struggled to engage the resident in activities, contributing to the deficiency.
A facility failed to identify the need for a guardian for a resident with severe cognitive impairment, despite policies requiring social services to assist in healthcare decisions. The resident, with a BIMS score indicating severe impairment, was initially their own responsible party. The Social Services Director acknowledged the oversight, and the Director of Nursing and Administrator expected staff to provide necessary social services.
A resident with a history of anxiety disorder was prescribed diazepam without a stop date or documentation of behavior monitoring and non-pharmacological interventions. The facility's staff failed to adhere to policies requiring documentation of medication effectiveness and side effects, leading to a deficiency in managing the resident's antianxiety medication.
A facility reported a medication error rate of 13.79%, exceeding the acceptable threshold of 5%. Two residents were affected by errors, including incorrect medication types and missed doses. Staff acknowledged the mistakes, which involved not adhering to prescribed orders and failing to double-check medication labels against the MAR.
A resident with a history of chronic respiratory failure and diabetes required Enhanced Barrier Precautions (EBP) due to klebsiella pneumoniae in their urine. However, a CNA failed to wear the necessary PPE, including a gown and mask, while providing incontinence care, despite signage indicating the need for EBP. Interviews with staff revealed inconsistencies in adhering to EBP protocols, contributing to the deficiency.
Failure to Use Resident-Specific Pain Assessment Methods
Penalty
Summary
Facility staff failed to use a resident-specific pain assessment for a resident with diagnoses including bipolar disorder, dementia, and gait abnormalities. The facility's policy required staff to consider cognitive and other individual factors when assessing pain and to use a standardized pain assessment instrument appropriate to the resident's cognitive level. Despite this, staff consistently used only the 0-10 numerical pain scale to assess the resident's pain, even though she was often unable to verbalize her pain level or assign a number to her pain. Interviews with staff, including an LVN, the Director of Staff Development, the Director of Nursing, the Medical Director, and the MDS nurse, confirmed that the resident's pain was assessed by observing facial expressions and assigning a number on the 0-10 scale, regardless of the resident's ability to communicate her pain verbally. Staff acknowledged that this approach was not best practice and did not align with facility policy, which called for descriptive documentation and the use of alternative pain assessment tools such as FACES or Wong-Baker when residents could not use the numerical scale. The record review showed that the resident's care plan included instructions to monitor for non-verbal signs of pain and to report symptoms such as changes in breathing, mood, or facial expressions. However, staff did not consistently follow these instructions or reassess the effectiveness of pain interventions as required by policy. Facility leadership confirmed that staff did not adhere to the pain assessment policy and that immediate education was needed.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Multiple deficiencies were identified in the facility's kitchen regarding food safety and sanitation practices. Observations revealed that the low temperature dishwasher's sanitizing solution was significantly below the manufacturer's recommended level, and expired test strips were being used to check the solution. Despite these findings, dietary staff continued to use the dishwasher and did not notify the Dietary Service Supervisor or switch to manual dishwashing immediately. When manual dishwashing was observed, staff were unsure of the required dwell time for sanitization and had no policy readily available for reference. The Director of Maintenance was unaware of the dishwasher issue at the time of the survey. Additional deficiencies included a primary handwashing sink for dietary staff that had low water flow and did not provide warm water, an issue known to both maintenance and management for an extended period. Expired tortillas and undated food items were found in dry storage, and dirty dishes were observed under a kitchen preparation table near clean dishes. The lid to a large container of dry powder thickener was left open when not in use, and thickened milk in the refrigerator was not dated when prepared. Facility policies required proper labeling, dating, and storage of food, which were not followed in these instances.
Failure to Maintain Safe, Clean, and Homelike Environment in Locked Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the locked unit. Ten out of twenty-one resident rooms were found to be undecorated and not personalized, lacking individual belongings or wall decorations. Multiple rooms and shared bathrooms had foul, urine-like or sewage-like odors, with sticky unknown stains on the floors. Some bathrooms had broken or mismatched toilet parts covered in tape, and a broken toilet paper dispenser. Several rooms and hallways had peeling, scratched, or patchy paint, with mismatched paint patches or drywall spackle visible, including large areas of paint missing near resident beds. An uncovered electrical outlet with patchy paint was also found near one room. The only outdoor recreation space for the locked unit was observed to have uneven pavement, dead plants, tall weeds, dead grass, no shade, and an overall unpleasant appearance. The courtyard was exposed to full sun and was adjacent to the facility's smoking area and storage sheds. Staff interviews confirmed awareness of the unpleasant odors, broken fixtures, and the need for improvements in both resident rooms and the courtyard. Facility policy indicated that staff should provide a personalized, homelike setting and encourage residents to use personal belongings, but these standards were not met in the observed areas.
Medication Error Rate Exceeds Acceptable Threshold Due to Policy and Procedure Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as 10 medication errors were observed out of 28 opportunities, resulting in a 35.7% error rate. Facility policy required medications to be administered according to prescriber orders, with staff verifying the right resident, medication, dosage, time, and method, as well as checking expiration dates. However, staff did not consistently follow these procedures. For example, a nurse documented a pain medication as refused when the resident only refused the applesauce it was mixed with, and did not offer an alternative food vehicle, despite knowing the resident's preference and the lack of pudding on the medication cart. Additionally, the same nurse failed to crush medications for another resident as ordered and did not check expiration dates prior to administration. Another nurse did not follow physician orders when administering vitamin C to a resident, giving four 250 mg tablets instead of two 500 mg tablets, and failed to check the medication against the MAR three times as required by facility policy. The nurse acknowledged the error and stated that the provider should have been contacted for a new order if the correct dosage form was unavailable. A registered nurse administering a corticosteroid inhaler did not follow the manufacturer's instructions, failing to instruct the resident on proper inhalation technique, breath holding, and mouth rinsing procedures. The nurse was unable to explain the differences between steroid and non-steroid inhalers or the importance of spitting out water after rinsing. The facility's Director of Nursing confirmed that staff are expected to follow both facility policy and manufacturer guidelines for medication administration.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and supplies. In one medication cart, nicotine patches were found unlabeled, lacking both the resident's name and expiration date. Similarly, another medication cart contained D-Mannose and Restasis vials that were not labeled with the resident's name or expiration date. These findings were confirmed by nursing staff, who acknowledged that the medications should have been properly labeled according to facility policy. Additionally, the inspection of a medication room revealed disorganized storage, with syringes and IV supplies scattered in unlabeled boxes and placed haphazardly on shelves. A resident's heart monitor was found stored under the sink among cleaning supplies, and wound care supplies were also unorganized and in unlabeled boxes. The unit manager confirmed responsibility for the organization of the medication room and acknowledged the improper storage and lack of accessibility for staff.
Failure to Provide Diet in Appropriate Form for Resident with Dysphagia
Penalty
Summary
A resident with diagnoses including Alzheimer's, underweight status, blindness, left hand contracture, and dysphagia was admitted to the facility and required a specialized diet. Dietary notes indicated that the resident's intake was low and that she was on a mechanical soft diet with pureed meat and fortified foods. On one occasion, the Infection Preventionist observed the resident spitting out vegetables and carbohydrates, and subsequently downgraded her diet to all pureed textures for swallowing safety. The physician and responsible party were notified, and the charge nurse and dietary staff were informed of the change. Physician orders were updated to reflect a fortified, pureed diet. Despite the updated diet order, the resident continued to receive the previous diet of pureed meats only for 33 days, as the change was not communicated to the Registered Dietitian. During an observation, the resident was seen eating pureed food with her hands and had difficulty locating her food, with her tray containing items inconsistent with her dislikes and dietary needs. The Registered Dietitian confirmed that the resident had been receiving the discontinued diet and updated the order for dietary staff after being made aware of the issue.
Failure to Report COVID Outbreak and Lapses in Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in two specific deficiencies. First, during a COVID outbreak, the Infection Preventionist (IP) did not report the outbreak to the California Department of Public Health (CDPH) as required by facility policy, which states that communicable disease outbreaks must be reported to appropriate agencies within 24 hours. The IP reported the outbreak to the local public health office but did not notify CDPH, stating uncertainty about the reporting requirement. Second, a Certified Nursing Assistant (CNA) did not follow proper hand hygiene protocols while providing care to a resident who was dependent on staff for all activities of daily living and had multiple medical conditions, including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes. During incontinence care, the CNA failed to remove soiled gloves and perform hand hygiene before handling clean items and moving from a soiled to a clean body site. The CNA also did not perform hand hygiene after removing soiled gloves and before donning new gloves, contrary to facility policy and infection control standards.
Failure to Maintain Working Call Light System for Multiple Residents
Penalty
Summary
The facility failed to ensure that a functioning call light system was available in each resident's bathroom and bathing area for five of seven sampled residents. Instead of repairing or replacing broken call light cords in a timely manner, the facility provided hand bells to residents whose call lights were not working. Observations confirmed that residents were using hand bells, and staff interviews revealed that these bells could not be heard from other rooms or the nurse's station, resulting in delayed or missed responses to residents' requests for assistance. Residents affected by this deficiency included individuals with significant medical needs and mobility limitations, such as heart disease, muscle weakness, unsteadiness, dementia, depression, vertigo, stroke, and difficulty walking. Care plans for these residents specifically required that call lights be kept within reach and that staff respond promptly to requests for assistance. Despite these documented needs, the broken call light cords were not repaired for extended periods, with maintenance logs showing delays in ordering and installing replacement parts. The Director of Maintenance acknowledged that broken call light cords accumulated because of time constraints and delays in receiving ordered parts. Maintenance records indicated that some residents had been using hand bells for several weeks, and staff confirmed that this was a temporary solution due to the lack of available working call light cords. The facility's own policies required timely maintenance of equipment, but these were not followed, resulting in the ongoing use of inadequate communication devices for residents in need.
Inaccurate Assessment of Resident's Eating Assistance Needs
Penalty
Summary
The facility failed to accurately assess a resident's need for assistance with eating, as evidenced by discrepancies between the Minimum Data Set (MDS) and the resident's care plan. The MDS assessment indicated that the resident required partial to moderate assistance with eating, while the care plan documented a need for extensive assistance. This inconsistency was not identified or reconciled by facility staff, resulting in an inaccurate reflection of the resident's care needs. The resident in question had multiple diagnoses, including Alzheimer's disease with late onset, underweight status, vascular dementia, glaucoma, blindness in one eye, a contracture in the left hand, and dysphagia. Observations showed the resident eating independently with her hands due to visual impairment, but also sitting idle at times until staff provided assistance. Interviews with the DON and MDS nurse confirmed the care plan required extensive assistance, and acknowledged the inconsistency between the care plan and the MDS assessment.
Failure to Develop Baseline Care Plan for Resident's Respiratory Needs
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who required respiratory care and continuous oxygen support. Upon review, the resident was admitted with acute respiratory failure, heart failure, pneumonia, and chronic obstructive pulmonary disease, and had physician orders for continuous oxygen via nasal cannula at 2 liters per minute. Observation showed the resident receiving oxygen and experiencing difficulty breathing while lying flat. However, the baseline care plan did not document the resident's need for oxygen or any respiratory problems. Interviews and record reviews confirmed that the baseline care plan omitted necessary respiratory goals and interventions, despite the resident's significant respiratory diagnoses and ongoing oxygen therapy. The Director of Nursing acknowledged that the care plan should have included these elements to address the resident's immediate health and safety needs as required by facility policy.
Failure to Specify Required Staffing for Dependent Resident's ADL Care
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that accurately reflected a resident's need for assistance with activities of daily living (ADLs), specifically the requirement for two staff members to assist with turning in bed, bathing, and changing briefs. The resident, who was readmitted after a hospital stay with multiple diagnoses including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes, was assessed as being severely cognitively impaired and fully dependent on staff for ADLs. The resident's Minimum Data Set (MDS) indicated a need for two or more helpers for these tasks, but the care plan did not specify the number of staff required for assistance. During observation, a CNA was seen changing the resident's brief alone, and the CNA stated she was unaware if two people were needed for the task. The care plan only noted that the resident required extensive to total assistance with ADLs but did not detail the number of helpers needed. The Director of Nursing confirmed that the care plan lacked this critical information, despite the resident's dependency and the facility's policy requiring comprehensive care plans with measurable objectives and timetables based on assessment findings.
Failure to Provide Required Assistance with Eating
Penalty
Summary
Resident 7, who has diagnoses including Alzheimer's disease, vascular dementia, underweight status, blindness in one eye, contracture of the left hand, and dysphagia, was care planned to require extensive assistance with meals due to her inability to verbalize needs and significant self-care deficits. The care plan specified that all needs must be anticipated and met, and that the resident required one-on-one assistance during meals. Facility policy also required that residents unable to perform activities of daily living independently receive necessary services to maintain good nutrition. Despite these requirements, observation revealed that Resident 7 was left to eat her pureed meal without assistance, using her hands due to her visual impairment and contracture, and at times not eating at all. Staff only provided assistance after approximately ten minutes. Interviews with the Infection Preventionist and the DON confirmed that the resident could not appropriately eat pureed foods with her hands and that her care plan required extensive assistance, which was not provided during the observed meal.
Failure to Evaluate and Document Skin Condition in Dependent Resident
Penalty
Summary
The facility failed to evaluate and document a red area on a resident's bottom following her readmission after a hospital stay. Upon admission, the resident was noted to have redness on her sacrum, but there were no documented measurements or identified causes for the redness. Over the next three weeks, weekly skin assessments indicated no new skin issues and described the skin as clear and intact, despite the presence of the red area. Staff interviews confirmed that the redness was not measured or evaluated, and there was no follow-up documentation regarding its progression. The resident involved had significant medical conditions, including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes, and was dependent on staff for all activities of daily living. She was always incontinent of urine and feces, increasing her risk for skin breakdown. Observations revealed that the resident continued to have a large, purple/red area with peeling skin on her bottom, and staff confirmed that daily treatments were being performed without proper documentation or evaluation of the wound's status.
Failure to Remove Hazardous Items and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision for a resident with dementia, psychotic disturbance, visual hallucinations, and anxiety disorder. The resident was found in possession of nine double-bladed disposable razors and one pair of tweezers in her room, despite facility policy requiring staff to identify and prevent accident hazards and to supervise residents according to their assessed needs. Staff were aware the resident had tweezers but were unaware of the razors, and indicated discomfort entering the resident's room due to her combative behavior. The resident had visible redness, inflammation, and scabs on her upper lip, which she attributed to tweezing, and expressed concerns about needing to protect her belongings from others. Interviews with staff confirmed that the presence of razors and tweezers in the resident's room was a safety concern, particularly given her cognitive and behavioral diagnoses. The Director of Nursing was surprised staff knew about the tweezers and confirmed that such items should not be accessible to the resident. The facility's failure to remove these items and provide appropriate supervision created a situation where the resident could have caused harm to herself or others.
Dietary Staff Lacked Competency in Manual Dishwashing Procedures
Penalty
Summary
The facility failed to ensure that three dietary aides responsible for dishwashing were competent in the use of the three-compartment sink procedure for manual dishwashing in the kitchen. During observation, a dietary aide was found using the dishwasher to sanitize dishes, but when asked to test the sanitizer level, the test strips indicated a concentration of 10 ppm, which was below the required 200 ppm per manufacturer instructions. The test strips used were also expired. Despite these findings, the dietary aides continued to use the dishwasher and did not notify the Dietary Service Supervisor or initiate manual dishwashing using the three-compartment sink. Further observation revealed that when manual dishwashing was eventually started, a dietary aide was unsure of the required dwell time for sanitization and confirmed that there was no policy regarding dwell time readily available. Manufacturer guidelines indicated that surfaces needed to remain wet for at least 60 seconds, but this information was not known or accessible to the staff. The Registered Dietitian confirmed that expired test strips should not be used, and staff should be aware of proper procedures, including dwell time. The Director of Maintenance was unaware of any issues with the dishwasher.
Failure of Medical Director Oversight During Scabies Outbreak
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) adequately supervised the development and implementation of measures to mitigate a scabies outbreak, which ultimately affected 31 residents and persisted for six months. The Medical Directorship Agreement specified that the MD was responsible for coordinating medical care, reviewing incidents, and serving on the infection control committee. Despite these responsibilities, documentation and interviews revealed that the MD was not fully aware of the extent of the outbreak, did not track or trend scabies cases, and was unclear about the procedures for diagnosing scabies within the facility. Infection control meeting minutes showed ongoing issues with skin infections and housekeeping practices, but lacked detailed discussion or resolution of the scabies outbreak. Medical records indicated that residents received various treatments for scabies and related skin conditions, including permethrin, ivermectin, and topical steroids, with some cases requiring dermatology consultations after prolonged symptoms. The MD acknowledged that best practice involves two treatments of permethrin and that unresolved cases should be further investigated, but was unaware of the number of affected residents and the specifics of diagnostic procedures. Infection control documentation was inconsistent, with incomplete action plans and missing follow-up on deep cleaning and staff education, contributing to the prolonged outbreak and lack of effective resolution.
Failure to Implement Effective QAPI Response to Scabies Outbreaks
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program as required, specifically in response to two documented scabies outbreaks. The QAPI committee did not develop, implement, or identify performance improvement activities related to these outbreaks. Review of the facility's QAPI policy indicated a requirement for ongoing, data-driven quality management, but records showed that outbreak tracking tools were incomplete, with missing information on specimen collection, lab results, prescribed treatments, recovery dates, and resident status for affected individuals. Additionally, documentation of medical director notification was inconsistent or lacked specific dates. Meeting minutes from infection control and QAPI meetings revealed insufficient documentation and follow-through regarding the scabies outbreaks. While some references to skin issues and in-service education were noted, there was a lack of detailed tracking, trending, or evaluation of corrective actions. In particular, the July meeting minutes did not include any mention of the scabies outbreak or related performance improvement actions, and there were no QAPI minutes available for a three-month period during which the outbreaks occurred. Interviews with facility leadership, including the DON, Infection Preventionist, and Administrator, confirmed that documentation was lacking in terms of tracking, trending, and evaluating the facility's response to the scabies outbreaks. The absence of comprehensive records and performance improvement activities resulted in 31 residents, as well as all staff, vendors, and visitors, being at risk for exposure to scabies.
Failure to Meet Professional Standards During Scabies Outbreak
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a scabies outbreak, specifically in the care of one resident with severe cognitive impairment and multiple comorbidities. The resident experienced ongoing skin issues, including excoriations and rashes, over several months. Initial treatments included topical steroids and permethrin cream, but documentation shows that the recommended two treatments of permethrin were not consistently administered, and the resident continued to experience symptoms. The outbreak was widespread, affecting multiple residents, and the facility's outbreak tracking indicated a significant number of cases. There were lapses in the diagnostic process for scabies. Skin scrapings to test for scabies were performed by licensed nurses who were not trained in the procedure and did not have physician orders to do so. The Infection Preventionist and DON confirmed that licensed nurses were not trained or authorized to perform skin scrapings, and the Medical Director stated that only trained professionals should conduct such tests, with samples sent to a laboratory for confirmation. Despite ongoing symptoms and repeated documentation of rashes and itching, there were delays in obtaining a dermatology consult and in confirming the diagnosis of scabies. The facility's Infection Control Program, as outlined in the job description, required the Infection Preventionist to coordinate and direct infection control measures, including ensuring proper isolation and precautions for residents with communicable diseases. However, the lack of training for staff on scabies identification and testing, as well as the failure to follow best practices for treatment and diagnosis, contributed to the prolonged outbreak and inadequate care for affected residents.
Failure to Identify, Manage, and Control Scabies Outbreak
Penalty
Summary
The facility failed to identify and manage a scabies outbreak, resulting in the spread of the infestation among 31 residents and one direct care staff member. The surveillance system, specifically the outbreak line listings, was incomplete and lacked essential information such as specimen collection dates, lab results, prescribed medications, recovery dates, and current status for affected residents. The Infection Preventionist confirmed that these omissions hindered the ability to track and trend the outbreak effectively. Additionally, the infection control committee did not consistently document or discuss the outbreak in their meeting minutes, and there was no evidence of tracking, trending, or consistent plans to mitigate the outbreak. Nursing and housekeeping departments did not implement appropriate precautions to prevent the spread of scabies. Documentation showed delays and gaps in deep cleaning of affected rooms, and the Director of Housekeeping was unable to provide evidence of when deep cleaning started or stopped for rooms impacted by scabies. Staff education on scabies was not provided until four months after the initial cases were identified, indicating a significant delay in training direct care staff on infection prevention and control practices specific to scabies. Two residents with severe cognitive impairment were directly affected by the outbreak. One resident experienced ongoing skin issues, including rashes and itching, with delayed diagnostic and treatment interventions. There was confusion and inconsistency in the management of their condition, including inappropriate in-house diagnostic procedures and delayed dermatology consultation. The roommate of this resident also exhibited symptoms and was placed on isolation and treatment for possible scabies exposure. The medical director was not fully aware of the extent of the outbreak, as indicated by the line listings.
Unlocked Bed Wheels Pose Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents by not locking the wheels attached to the headboards of beds, which posed a risk of accidents or injuries. This deficiency was observed in three residents who were sampled for accidents. Resident 1, who had a history of falls and a recent hip fracture, attempted to get out of bed without assistance, causing the bed to move due to unlocked wheels. This incident resulted in Resident 1 soiling herself as she was unable to reach the bathroom in time. Further observations revealed that the beds of Residents 4 and 8 also had unlocked wheels, which could have led to falls during transfers. Resident 4, who had a history of stroke and muscle weakness, and Resident 8, who had dementia and mobility issues, were both unaware that their bed wheels were unlocked. The Occupational Therapist noted that the bed movement had occurred during resident transfers, highlighting the potential for falls. Interviews with staff, including the Director of Maintenance and the Assistant Director of Nursing, confirmed that there was no specific policy for bed safety, and it was expected that CNAs ensure the wheels were locked. The Director of Maintenance stated it was not his responsibility to check the bed wheels, while the ADON acknowledged that CNAs might forget to lock the wheels after moving beds for resident care. The lack of a clear policy and responsibility for ensuring bed safety contributed to the deficiency.
Failure to Respect Resident's Dignity and Toileting Needs
Penalty
Summary
The facility failed to treat a resident with dignity and respect by making them wear an incontinent brief and not assisting them to the bathroom for toileting. The resident, who was cognitively intact and continent of bowel and bladder, was admitted with a hip fracture and other medical conditions. Despite having a discharge order for weight bearing as tolerated on the right leg, the staff did not get the resident out of bed for seven days, forcing them to use a bedpan instead of being taken to the bathroom. Interviews with staff and the resident confirmed that the resident was upset and frustrated by the situation. The facility's policies on dignity and resident rights were not adhered to, as the resident's needs and preferences were not respected. The nursing staff failed to review the discharge orders properly, which led to the oversight in the resident's care plan, resulting in a dignity issue.
Incomplete Care Plan for Resident Post-Surgery
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, resulting in unrecognized individual care needs. The resident, who was admitted with a history of right breast cancer and a mastectomy, did not have restrictions documented in the care plan to prevent the use of the right arm for blood pressure measurements or procedures. This oversight was confirmed during an interview with a licensed nurse, who acknowledged the absence of these restrictions in the care plan. Additionally, the resident had undergone right hip surgery and had a discharge order for weight-bearing as tolerated, but this was not included in the care plan, leaving nursing staff without guidance on the resident's mobility and transfer needs. Furthermore, the care plan did not address the monitoring of surgical incision sites on the resident's right leg, which had 13 staples. There were no instructions for observing signs of infection or for the removal of the staples. This lack of specific interventions was confirmed by a licensed nurse during an interview. The failure to include these critical elements in the care plan resulted in the potential for a decline in the resident's physical, mental, and psychological status, as their care needs were not adequately recognized or addressed.
Failure to Assist Resident Out of Bed Post-Surgery
Penalty
Summary
The facility nursing staff failed to assist a resident in getting out of bed following hip surgery, despite the resident's request and medical orders allowing for weight-bearing as tolerated. This oversight occurred for seven consecutive days, during which the resident remained in bed, potentially leading to emotional distress and negative clinical outcomes related to immobility. The facility's policies on dignity and resident rights emphasize the importance of honoring resident preferences and ensuring participation in care planning, which were not adhered to in this case. The resident, who was cognitively intact and capable of making her own decisions, had been admitted with a hip fracture and other medical conditions, including Parkinson's disease and a history of breast cancer. Despite having discharge orders from the hospital indicating activity as tolerated and no restrictions on getting out of bed, the nursing staff did not facilitate the resident's mobility. The failure to incorporate these orders into the care plan was confirmed by a licensed nurse, who acknowledged that the resident should have been assisted out of bed to prevent further complications.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility nursing staff failed to complete and accurately document medical records for a resident, specifically regarding activities of daily living (ADLs). The facility's policy requires that all services provided to residents, progress towards care plan goals, and changes in residents' conditions be documented in their medical records. However, a review of the resident's medical record revealed missing documentation for several days concerning bathing, bed mobility, bladder and bowel incontinence, dressing, fluid intake, transfers, positioning, walking, wheelchair mobility, hygiene, food intake, and vital signs. The resident involved was admitted with multiple diagnoses, including a hip fracture, Parkinson's disease, depression, and a history of breast cancer. The resident was cognitively intact and required substantial assistance with various ADLs. Despite these needs, there were significant gaps in the documentation of care provided, which was confirmed by a licensed nurse and the facility administrator during interviews. This lack of documentation could potentially lead to unmet resident needs and negative clinical outcomes.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician in a timely manner when a resident experienced a change in condition, resulting in the resident not receiving timely evaluation and treatment. The resident, who had a history of congestive heart failure, COPD, type II diabetes, and a brain tumor, was admitted with a Do-Not-Resuscitate status. Despite being cognitively intact, the resident experienced vomiting, decreased meal intake, and low blood pressure, and refused to be transported to a hospital for further evaluation. On the morning of the resident's death, a phlebotomist attempted to draw blood but found the resident unresponsive and in a compromised state, with fecal matter on the floor and on the resident. The phlebotomist did not verbally ask the resident for a lab draw due to the situation and reported the condition to a staff member, who then informed the LVN. However, no further action was taken to assess the resident's condition or notify the physician, as required by the facility's policy. Interviews with staff revealed a lack of communication and follow-up after the phlebotomist's report. The CNA on duty did not check on the resident after the initial observation, and the resident was found unresponsive later that morning. The Director of Nursing confirmed that the facility's expectation was for staff to check on residents every two hours and report any changes promptly, which did not occur in this case.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to provide timely and accurate discharge planning for a resident, resulting in the potential for an unsafe discharge and causing anxiety for the resident. The resident, who had a history of congestive heart failure, COPD, type II diabetes, and a brain tumor, was cognitively intact with a BIMS score of 15. Despite the resident's desire to be discharged to a family member's home out of state, the facility did not provide a 30-day notice of discharge, nor was there a physician order to initiate discharge planning. The resident's care plan indicated a functional decline requiring assistance with ADLs, and the level of care was appropriate for residential care in the facility. The discharge planning process was inadequately documented, with only one note in the resident's documentation. The pharmacy was unable to fulfill a medication refill request due to insufficient notice, as the resident was given less than 24-hour discharge notice. Interviews with facility staff, including a CNA, NP, DON, SSD, and Admin, revealed a lack of communication and coordination in the discharge planning process. The SSD confirmed the absence of discharge planning notes and cited staffing issues in the social services department. The Admin admitted to initiating the discharge based on a discussion, without proper documentation or coordination with the medical team.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, leading to discrepancies in the documentation of their behaviors and needs. Resident #49 was admitted with a history of dementia and exhibited behaviors such as wandering, yelling, and rejection of care, which were not accurately reflected in the MDS. Despite documented instances of these behaviors within the seven-day lookback period, the Social Services Assistant (SSA) did not code them due to a lack of documentation in the progress notes, relying instead on staff statements and not referring to the elopement assessment. Resident #81, with severe cognitive impairment, was documented to have wandered and entered other residents' rooms, yet the MDS did not reflect these behaviors. The SSA responsible for coding the MDS did not include these behaviors due to the absence of documentation in the progress notes, despite staff observations and elopement risk assessments indicating otherwise. The Social Services Director (SSD) confirmed that the MDS was only coded based on available documentation, and the elopement assessments were not considered. Similarly, Resident #59 and Resident #58 exhibited behaviors such as wandering, yelling, and rejection of care, which were not accurately coded in their MDS. The SSA and SSD both stated that behaviors were only coded if documented in the progress notes, and elopement assessments were not utilized in the coding process. Interviews with staff, including the Director of Nursing (DON), highlighted the importance of accurate MDS coding for tracking resident changes and ensuring appropriate care, yet the facility's reliance on incomplete documentation led to inaccuracies in the MDS for these residents.
Failure to Implement Care Plan for Wandering Resident
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident identified as an elopement risk and wanderer. The resident, who had a medical history of moderate dementia with psychotic disturbance, recurrent major depressive disorder, anxiety disorder, disorientation, and unspecified intellectual disabilities, was admitted to the facility in March 2021. The resident's care plan, revised in August 2023, included interventions to prevent wandering, such as offering diversions, structured activities, and reorientation strategies. However, during an observation in July 2024, the resident was seen wandering into other residents' rooms and lying on another resident's bed, indicating that the care plan interventions were not effectively implemented. The Director of Nursing acknowledged that the resident frequently walked from place to place and entered other residents' rooms, exhibiting some aggressive behaviors. Despite the care plan's directives, the staff struggled to engage the resident in sit-down activities, although they attempted to involve the resident in some form of activity. This lack of effective implementation of the care plan interventions contributed to the deficiency, as the resident's wandering behavior was not adequately managed, leading to potential disturbances in the living environment of other residents.
Failure to Identify Guardian Need for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services by not identifying the need for a guardian for a resident with severe cognitive impairment. The resident, admitted with a history of hemiplegia, hemiparesis, aphasia, and other conditions, was initially recorded as their own responsible party. However, subsequent assessments revealed severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 1, indicating the resident's inability to make informed decisions. Despite this, the facility did not take steps to appoint a guardian, as noted in interviews with the Social Services Assistant and Director, who acknowledged the oversight. The facility's policy and job description for the Social Services Director emphasize the responsibility to assist residents in obtaining necessary resources and making healthcare decisions. However, the Social Services Director admitted that the resident should have had a guardian upon admission, and the facility failed to initiate the process to change the resident's capacity status. The Director of Nursing and the Administrator both expressed expectations that staff should provide necessary social services to ensure residents receive appropriate support, highlighting a lapse in the facility's adherence to its policies.
Failure to Manage Antianxiety Medication Use
Penalty
Summary
The facility failed to properly manage the use of an antianxiety medication for a resident, identified as Resident #27, who had a medical history of schizoid personality disorder and anxiety disorder. The resident's care plan did not include behaviors or the use of an antianxiety medication, despite having a physician's order for diazepam 2 mg to be administered as needed every morning for anxiety. The order lacked a stop date, specific behaviors to monitor, non-pharmacological interventions to try before administering the medication, and instructions for monitoring side effects or effectiveness. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the resident showed that diazepam was administered daily over a period without documentation of behavior monitoring, non-pharmacological interventions, or monitoring for side effects. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed a lack of awareness regarding the need for a stop date for PRN psychotropic medications and inconsistent documentation of non-pharmacological interventions and behavior monitoring. The Medical Director, who was also the resident's Primary Care Provider, confirmed that the diazepam should have had a stop date and expected staff to document behaviors and try alternatives before administering PRN medications. The facility's policy on psychotropic medication use required documentation of the rationale for extended PRN orders and monitoring of side effects, which was not adhered to in this case.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 13.79%. This deficiency was identified during a medication administration task involving four errors out of 29 opportunities, affecting two residents. Resident #10, who has a medical history including protein-calorie malnutrition and bradycardia, was administered the wrong type of aspirin and a multivitamin without minerals, contrary to the prescribed orders. The administering nurse, RN #11, acknowledged the errors, noting that she failed to double-check the medication labels against the orders and the medication administration record (MAR). Resident #33, diagnosed with idiopathic peripheral autonomic neuropathy, experienced medication administration errors when Linzess was given late and after the resident had eaten, and topiramate was omitted entirely. MDS Coordinator #13, who administered the medications, confirmed these errors, admitting to not realizing the resident had already eaten and missing the administration of topiramate. Interviews with the facility's Administrator and Director of Nursing highlighted the expectation for nurses to adhere to the five rights of medication administration and to follow physician orders precisely, emphasizing the importance of timely and accurate medication delivery.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program for Resident #8, who was admitted with a medical history including chronic respiratory failure and diabetes. The resident required substantial assistance with toileting hygiene and was frequently incontinent. An order for Enhanced Barrier Precautions (EBP) was in place due to the presence of klebsiella pneumoniae in the resident's urine, necessitating the use of gown, gloves, and face shield during high-contact care activities. However, during an observation, CNA #2 entered the resident's room, which had enhanced standard precaution signage, wearing only gloves while performing incontinence care, failing to don a gown and mask as required. Interviews with facility staff, including CNA #2, the Infection Preventionist, the Director of Nursing, and the Administrator, revealed a lack of adherence to EBP protocols. CNA #2 admitted to not noticing the precaution signage and acknowledged not wearing the appropriate PPE due to missing in-service training sessions. The Infection Preventionist and the Director of Nursing confirmed that PPE should be used for residents with MDROs, and the Administrator emphasized the importance of EBP to prevent infection spread. Despite training and signage, the staff did not consistently implement the necessary precautions, leading to the deficiency.
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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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