Rosecrans Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardena, California.
- Location
- 1140 West Rosecrans Avenue, Gardena, California 90247
- CMS Provider Number
- 055072
- Inspections on file
- 35
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Rosecrans Care Center during CMS and state inspections, most recent first.
A resident with DM, COPD, severe cognitive impairment, and a sacral pressure ulcer experienced a significant change in condition when the ulcer progressed from Stage 2 to Stage 4 after readmission from a hospital. The TXN documented the Stage 4 ulcer on an admission skin reassessment and stated this progression was a significant change, and reported notifying the physician, nurse, and CNA but only attempting once to call the resident’s responsible party, without successful contact or voicemail. The DON stated that licensed nurses are responsible for notifying responsible parties of significant changes, and facility policy requires notifying a resident’s representative of significant physical, mental, or psychosocial changes, but the responsible party was not successfully notified in this instance.
Two residents were involved in an altercation in which one resident, with schizoaffective disorder and a history of aggression, entered another resident’s room and later reported being struck with a foldable chair. An RN responded after hearing screaming and, along with the ADON, confirmed that the aggressive resident continued to have episodes of yelling while awaiting transfer. Although the resident’s care plan called for early redirection and de-escalation techniques and facility policy required documentation of behavioral changes and interventions, the progress notes for that day did not record any behavioral interventions, redirection, de-escalation efforts, or non-pharmacological measures taken during the episode.
A resident with dementia, metabolic encephalopathy, epilepsy, and muscle weakness, and severely impaired cognition, developed a large dark bruise with swelling under the left eye that was unwitnessed and could not be explained, meeting the facility’s definition of an injury of unknown source. The DON and an LVN acknowledged that such injuries must be reported within 2 hours federally and within 24 hours to the state, and facility policy required reporting unusual occurrences and injuries affecting health and safety within 24 hours. Despite these requirements, the unwitnessed facial injury and resulting discoloration were not reported to the state agency within the mandated timeframe, resulting in a deficiency for failure to timely report suspected abuse, neglect, or injury of unknown source.
Surveyors found that the facility did not follow its policy requiring daily monitoring and documentation of refrigerator and freezer temperatures for multiple kitchen units. Temperature logs for three refrigerators (Produce and Breads, Milk and Dairy, Nourishment) and two freezers (Frozen Vegetables and Ice Cream, Frozen Meat) contained blank entries on several morning and evening shifts, indicating that required checks were not completed. The Dietary Supervisor reported that AM and PM cooks were responsible for these checks and acknowledged that failure to monitor and document temperatures could lead to food spoilage, contrary to the facility’s written standards for maintaining safe food storage temperatures.
Surveyors observed that one shower room had dry brown fecal matter on a shower stall wall and a small drop of feces on the floor, and a housekeeper acknowledged that not cleaning and disinfecting these surfaces could make residents sick. Review of the housekeeper job description showed that staff are required to follow infection prevention and control procedures, including cleaning and disinfecting walls and ceilings to remove contaminants with proper solutions. The facility’s infection control policy stated that its practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections, but these procedures were not implemented in this shower area.
Certified nursing assistants failed to fully close privacy curtains while providing ADLs, including incontinent care, to three residents with varying levels of cognitive and physical impairment. In each case, residents were left exposed or visible to others, despite staff acknowledging the importance of privacy and facility policies requiring it.
A resident with dementia and a history of wandering was not properly monitored during the night shift, resulting in her entering another resident's room and becoming trapped in her wheelchair. The incident was discovered after a roommate alerted staff, and documentation showed that required monitoring of the wandering behavior was not completed. Staff interviews confirmed awareness of the resident's wandering and the need for supervision, but facility policies for monitoring and supervision were not followed.
A resident with a history of stroke and high risk for bleeding was prescribed both aspirin and Eliquis for CVA prophylaxis. Despite care plan requirements to monitor for bleeding and bruising every shift, staff failed to document any such monitoring over several weeks. The DON confirmed that monitoring for adverse effects of anticoagulant therapy was not performed as required.
Surveyors found that several medications, including eye drops, an inhaler, insulin, lorazepam, and gabapentin, were either not labeled with open dates or not stored according to manufacturer requirements. An LVN confirmed that some medications requiring refrigeration were left at room temperature and that doses had been administered from improperly stored bottles.
A resident with multiple chronic conditions was observed receiving IV fluids through a catheter that lacked a date of insertion on the dressing, contrary to facility policy. Nursing staff confirmed responsibility for IV care and documentation but were unable to explain the missing date label, which is necessary for proper site management.
A resident dependent on supplemental oxygen did not have their oxygen saturation (O2 sat) levels checked every shift as ordered, despite physician instructions to monitor and titrate oxygen to maintain O2 sat at 92% or above. Documentation showed multiple missed O2 sat checks, and an LVN confirmed the monitoring was not consistently performed, contrary to facility policy.
Multiple rooms were found to be below the required minimum square footage per resident, with some rooms housing more beds than the available space allows. A review of facility records and a waiver request confirmed the deficiency, and the Adm acknowledged that while residents had not complained, the limited space could make care provision challenging for staff.
A resident with a history of polyneuropathy, repeated falls, and diabetes mellitus repeatedly reported severe pain after being struck, but no pain medication was administered despite an active physician order and documentation of pain at the required threshold. Both the LVN and DON confirmed that pain was documented but not treated, in violation of facility policy and physician orders.
Two residents with stage 4 pressure ulcers had their wound dressings unlabeled, contrary to the facility's policy requiring nurse initials, time, and date. An LVN admitted to not labeling the dressings, and the DON confirmed the policy was not followed, potentially risking wound infections and delayed healing.
The facility failed to implement its Enhanced Standard Precautions policy, which requires healthcare workers to wear PPE when providing care to residents at high risk for MDRO transmission. Two residents with pressure ulcers did not receive care in accordance with this policy, as observed when LVNs performed wound care without wearing isolation gowns, despite ESP signs being posted. This failure had the potential to result in the transmission of disease-causing organisms and delay wound healing.
The facility failed to ensure clean linens were not placed near washing machines with dirty and soiled clothing. During an observation, 11 linen carts filled with clean linen were found alongside three washing machines with dirty linen washing inside. Both the Housekeeping Supervisor and the Administrator confirmed that this practice could lead to cross-contamination and spread of infection, violating the facility's policy on laundry and linen.
The facility failed to ensure staff promoted dignity while assisting a resident during meals. A CNA was observed standing over the resident and not maintaining face-to-face eye contact, which could make the resident feel rushed and affect their dignity. Staff interviews and the resident's feedback confirmed the importance of assisting at eye level to promote comfort and dignity.
A resident with multiple diagnoses, including schizoaffective disorder and major depressive disorder, was administered Seroquel without documented informed consent. Facility staff confirmed that informed consent is required before administering psychoactive medications, but this policy was not followed.
The facility failed to ensure a safe, clean, and homelike environment for a resident with moderate cognitive impairment and multiple health conditions. The resident's room had chipping paint and visibly soiled walls, which were acknowledged by the Maintenance Supervisor, Housekeeping Supervisor, and Director of Nursing as unacceptable and potentially posing an infection control issue.
The facility failed to ensure an accurate MDS assessment for a resident regarding the pneumococcal vaccine. The resident, who was not eligible for the vaccine, was incorrectly documented as having declined it. The MDS Nurse confirmed the inaccuracy, and there was no supporting documentation in the resident's clinical records.
The facility failed to complete and resubmit the PASRR Level I screening and refer a resident with a new diagnosis of psychosis for a PASRR Level II evaluation. The resident's new diagnosis and use of psychotropic medication were not communicated to the business office, resulting in the case being closed without the required evaluation.
The facility failed to initiate a care plan for RNA services for a resident with ataxia, muscle weakness, repeated falls, and cardiomegaly. Despite physician orders for daily ambulation assistance, no care plan was created, potentially affecting the resident's care quality.
The facility failed to revise a resident's care plan to include a physician-ordered back brace for low back pain. Despite the order, the care plan was not updated, placing the resident at risk for inadequate back support.
The facility failed to provide adequate oral hygiene for a resident who was totally dependent on staff for daily living activities. The resident, with multiple diagnoses including cerebral infarction and diabetes, was observed with thick dried yellowish particles on her mouth and tongue. Despite the care plan specifying oral care every shift, this was not done, as confirmed by the DSD and DON.
The facility failed to provide a resident with her preferred activity of participating in group activities in the dining recreation area. Despite the resident's expressed desire and ability to participate, she remained in bed due to a lack of scheduling and limited supply of reclining wheelchairs. Staff confirmed there was no reason for her not to participate, and the Activity Director noted her absence from group activities.
A resident with limited range of motion was not provided with a left hand roll as ordered by the physician. Instead, the hand roll was incorrectly applied to the right hand, despite clear directives in the care plan and physician's orders. This error was confirmed by both the RNA and OT, highlighting a failure to follow the facility's policies on individualized, resident-centered care.
The facility failed to ensure a resident receiving hemodialysis had an emergency kit available at the bedside and did not communicate a fluid restriction recommendation from the dialysis center to the resident's physician. The absence of the emergency kit and lack of communication were confirmed by staff and violated the facility's policy.
The facility failed to label two medications with open dates and did not follow the manufacturer's guidelines for budesonide inhalation suspension for two residents. This was confirmed by an LVN and the DON, who emphasized the importance of documenting open dates to ensure medication potency and adherence to guidelines.
A resident with low back pain did not receive a physician-ordered back brace, despite the order being medically justified. Interviews and observations confirmed the back brace was not available, and there was a lack of communication between nursing staff and physical therapists. The facility's policy required therapeutic services to be provided upon a physician's written order.
A facility failed to offer the pneumococcal vaccine to a resident with multiple medical conditions, despite the resident being eligible according to the facility's policy. The Infection Preventionist Nurse did not document any offer, decline, or administration of the vaccine, increasing the resident's risk of developing pneumonia.
The facility failed to ensure that 17 resident rooms met the required square footage per resident, with multi-resident rooms measuring less than 80 square feet per resident and single-resident rooms measuring less than 100 square feet. The Administrator acknowledged the non-compliance but stated that resident care had not been affected. A waiver request had been submitted previously, indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy.
A resident with quadriplegia and significant mobility impairments sustained a right upper arm fracture due to inadequate supervision and assistance during ADLs. The care plan did not specify the need for two-person assistance, leading to a CNA providing care alone. This oversight resulted in the resident's injury and subsequent hospitalization.
A resident with quadriplegia and other severe impairments sustained a significant bruise and fracture, but the facility failed to report the incident to the State Survey Agency within the required two-hour window, delaying the investigation by over 24 hours.
Failure to Notify Responsible Party of Significant Change in Wound Status
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition. The resident was admitted and later readmitted with diagnoses including diabetes mellitus, a Stage 4 sacral pressure ulcer, and COPD. A History and Physical dated 1/14/2026 documented that the resident was non-verbal and lacked capacity to make medical decisions, and a subsequent MDS dated 2/28/2026 showed severe cognitive impairment with dependence on staff for toileting, bathing, and personal hygiene. Upon readmission from a general acute care hospital, the admission Skin Reassessment dated 2/25/2026 showed the resident now had a Stage 4 sacral pressure ulcer, whereas the Treatment Nurse stated the ulcer had been a Stage 2 prior to transfer. During interview, the Treatment Nurse stated that progression from a Stage 2 to a Stage 4 pressure ulcer was a significant change and that she notified the resident’s physician, nurse, and CNA, but was unable to notify the responsible party. She reported making one unsuccessful phone call to the responsible party and was unable to speak with them or leave a voicemail, and acknowledged she should have made another attempt. The DON stated that licensed nurses were responsible for notifying residents’ responsible parties when there was a significant change in condition and that such notification was important because it was the responsible party’s right to be informed and included in changes to the plan of care. The facility’s policy titled “Change in a Resident’s Condition or Status” indicated that, unless otherwise instructed by the resident, a nurse will notify the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status, which did not occur in this case.
Plan Of Correction
On March 5, 2026 the Treatment Nurse immediately notified the responsible party of the change in condition of the resident affected and documented this notification in the medical records. On March 5, 2026 the facility Social Services Department and Treatment Nurse interviewed residents' responsible party to address any concerns regarding the communication delay and Interdisciplinary Conference was scheduled for March 18, 2026. On March 5, 2026 the DON and Administrator issued a written warning and provided formal counseling to the treatment nurse for failing to document notifying the residents responsible party of the residents' change of condition. 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; The facility of Medical Records and DON conducted an audit of all residents who experienced a Change in Condition over the past 30 days and ensured that required notification to responsible parties were completed and properly documented. No other findings are noted. On March 6, 2026 and on March 20, 2026 the DON conducted a License Nurses in-service on the facility Change of Condition policy and procedure. The in-service focused on the critical requirement for timely notification of the responsible party and ensuring all communication is thoroughly documented. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;On March 6, 2026 and on March 20, 2026, License Nurses received in-service and education on the facility Change of Condition policy and procedure, emphasizing the requirement to notify residents' responsible parties of any significant changes in a timely manner and the importance of documenting.The Medical Records will perform weekly audits of residents with a change of conditions to verify that the responsible party was notified and that such notification was documented. Findings will be reported to the DON and Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system; andThe Medical Records will perform weekly audits of resident with a change of condition to verify that the responsible party was notified and that such notification was documented. These audits will continue weekly for four weeks, followed by monthly reviews for three consecutive months. Audit results will be reported to the facility QAPI Committee for further oversight and trend analysis.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.All corrective actions will be monitored daily, weekly compliance audits will be conducted by the Medical Record for four weeks then monthly for three months thereafter that with findings reported to the committee members during the facility's QAPI meeting.
Failure to Document Behavioral Interventions After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to document behavioral interventions as indicated on the care plan for a resident following an altercation with another resident. Resident 1 was admitted with diagnoses including anemia and schizoaffective disorder and had a documented episode of increased aggression on 2/28/2026, during which he was unable to be redirected and was considered a danger to others. On that date, Resident 1 entered Resident 2’s room, and RN 1 responded after hearing Resident 1 screaming in the hallway. RN 1 found Resident 2 holding a foldable chair, and Resident 1 reported that Resident 2 had hit him on the head with the chair. Resident 2 had been admitted with chronic kidney disease and hypertensive urgency. Resident 1’s care plan, dated 2/28/2026, included interventions for staff to provide early redirection and de-escalation techniques to reduce episodes of verbal aggression. Record review of Resident 1’s progress notes for 2/28/2026 showed that the incident occurred at 11:20 a.m. and that Resident 1 was picked up for transfer at 4:45 p.m., but the notes did not document any early interventions, redirection, or de-escalation measures taken during the period when Resident 1 was intermittently yelling while awaiting transfer. RN 1 acknowledged that the progress notes did not indicate early interventions, redirection, or de-escalation that were done during Resident 1’s episodes of screaming. The ADON confirmed that Resident 1 was alert, oriented, ambulatory, and had episodes of screaming on 2/28/2026, and stated that the progress notes did not document interventions, including non-pharmacological ones. The DON stated that care plan interventions should have been documented if they were completed and that following care plan interventions was important to prevent further behavioral escalation and to keep residents and staff safe. The facility’s policy on Behavioral Assessment, Intervention, and Monitoring required that any improvements or worsening in behavior, mood, and function, as well as new or emergent symptoms, be documented and reported.
Plan Of Correction
How corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice; On March 5, 2026 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) immediately reviewed and updated their care plan to ensure all behavior interventions are current. On March 5, 2026 the DON and Administrator counsel the charge nurse on the specific required documentation following an altercation. 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; The facility of Medical Records and DON conducted an audit of care plans for residents with known behavioral episodes were documented, and any discrepancies found during this audit were corrected immediately. On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;The Medical Records Director (or designee) will conduct daily audits of the Electronic Medication Administration Record (EMAR) behavior monitoring. These audits will ensure that for every resident with a documented behavior, corresponding care plan interventions are implemented and charted. All findings will be reported directly to the Director of Nursing (DON) and Administrator for review.On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system; andThe Medical Records will perform weekly audits of behavioral monitoring and progress notes for four weeks, then monthly for the three months. The results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee for further review and to determine if additional training or systemic adjustments are necessary.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.All corrective actions will be monitored daily, weekly compliance audits will be conducted by the Medical Record for four weeks then monthly for three months there after that with all findings reported to the committee members during the facility's QAPI meetings.
Failure to Timely Report Unwitnessed Injury of Unknown Source to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an unwitnessed injury of unknown source to the California Department of Public Health (CDPH) within the required 24-hour timeframe for one resident. The resident had diagnoses including metabolic encephalopathy, epilepsy, dementia, and muscle weakness, with documentation showing fluctuating decision-making capacity and severely impaired cognition. The Minimum Data Set indicated the resident required partial to moderate staff assistance for toileting hygiene, showers, and dressing. A Change of Condition note documented that the resident developed discoloration and swelling under the left eye, described as a dark purplish color. On observation, the resident was noted to have a large dark bruise partially around the left eye and was unable to explain how the injury occurred. Interviews and record reviews showed that the DON and LVN recognized the injury as an injury of unknown source, given that the incident was unwitnessed and the resident could not provide an explanation, consistent with the facility’s policy defining injuries of unknown source. Both the DON and LVN stated that such injuries should be reported within two hours federally and within 24 hours to the state. The facility’s “Unusual Occurrence Reporting” policy required notification to the Department of Health Services of all unusual occurrences, including facility-related injuries requiring medical treatment and other injuries affecting health and safety, within 24 hours. Despite this, the unwitnessed facial injury and resulting discoloration to the resident’s left eye were not reported to CDPH within the required timeframe, constituting the cited deficiency.
Plan Of Correction
How corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice; On March 3, 2026 Registered Nurse (RN) supervisor and Charge nurse conducted a comprehensive physical assessment of Resident 1 to rule out further injury and ensure their safety. No other injury was noted and safety precautions in place. Staff receive re-education on the facility's policy and procedure on March 5, 2026, regarding reporting of unwitnessed injury with emphasis on reporting with the 24-hour time frame given by the Director of Nursing (DON). 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; To identify if any residents could have been affected, on February 3, 2026 the DON and Medical Record staff conducted a facility-wide audit of all incident reports and clinical records from the past 30 days to ensure every unwitnessed injury or injury with unknown origin was reported to CDPH within the 24-hour regulatory window, none was noted. On March 5, 2026 and on March 10, 2026 the Director of Nursing provided in-service to the staff regarding the facility's Unusual Occurrence Policy and Procedure, emphasizing on the importance of reporting to CDPH within 24 hours for unwitnessed injury. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;The Director of Nursing (DON) on March 3, 2026 updated the Incident Monitoring Log to track whether incidents were witnessed or unwitnessed. The log now also includes resident cognition levels to ensure more accurate reporting to the CDPH.Director of Nursing (DON) conduct weekly audits of incident reports for six weeks, followed by monthly audits ongoing, to verify that every unwitnessed injury is investigated and reported within CDPHN 24-hour regulatory window. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system;To ensure ongoing compliance, the Director of Nursing (DON) and Administrator will perform a weekly audit of the Incident Monitoring Log, verifying that every unwitnessed incident with injury has been reported to the California Department of Public Health (CDPH) within acceptable time frame.Monitoring results will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) system monthly for three months, where the committee will review the data to evaluate the effectiveness of the corrective actions and make necessary changes.
Failure to Consistently Monitor and Document Refrigerator and Freezer Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its policy and procedure titled "Refrigerators and Freezers" requiring daily monitoring and recording of refrigerator and freezer temperatures. During an interview and concurrent record review with the Dietary Supervisor in the kitchen, temperature logs for three refrigerators and two freezers for the year 2026 were reviewed. The logs showed blank entries, indicating that monitoring was not completed on specific dates and shifts. For the refrigerators labeled Produce and Breads, Milk and Dairy, and Nourishment, temperature logs were blank for the morning shift on 1/1/2026 and 1/2/2026, and for Produce and Breads and Milk and Dairy on the evening shift on 1/1/2026. For the freezers labeled Frozen Vegetables and Ice Cream and Frozen Meat, temperature logs were blank for the morning shift on 1/1/2026 and 1/2/2026, and for the evening shift on 1/1/2026. The Dietary Supervisor stated that the AM and PM cooks were responsible for ensuring timely monitoring and documentation of refrigerator and freezer temperatures and acknowledged that lack of monitoring and documenting refrigerator and freezer temperatures may cause food spoilage. Review of the facility’s policy dated 11/2022 indicated that the facility would ensure safe refrigerator and freezer temperatures and sanitation, observe food expiration guidelines, and maintain refrigerators and freezers in good working condition. The policy specified that refrigerators must keep food at or below 41°F and freezers must keep frozen foods frozen solid, and that food service supervisors or designated employees must check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. The documented gaps in the temperature logs demonstrated that this policy was not followed on the identified dates and shifts.
Failure to Clean and Disinfect Fecal Contamination in Shower Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when, during an observation of the east shower room with a housekeeper, dry brown fecal matter was seen on the wall of the second shower stall and a small drop of brown feces was seen on the floor. The housekeeper acknowledged that failure to clean and disinfect the walls and floors may increase the risk of residents getting sick. Review of the housekeeper job description showed that housekeeping staff are required to perform cleaning procedures in accordance with established infection prevention and control procedures, including cleaning walls and ceilings by washing, wiping, spot cleaning, disinfecting, and deodorizing to remove dirt and other contaminants using proper cleaning and disinfecting solutions. Review of the facility’s infection control policy indicated that its infection 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 deficiency arose because the shower room surfaces contaminated with fecal matter were not cleaned and disinfected in accordance with the facility’s housekeeping job description and infection control policies, as evidenced by the observed fecal matter remaining on the shower wall and floor during the survey.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy during care for three residents when certified nursing assistants (CNAs) did not fully close privacy curtains while providing activities of daily living (ADLs), including incontinent care. Observations revealed that in each instance, the privacy curtain was only halfway closed, and in one case, the bedside window curtains were also open, making the resident visible from outside. These lapses occurred while residents were exposed or naked during personal care. Resident 2, who had diagnoses including generalized muscle weakness, lymphedema, and morbid obesity, was observed receiving incontinent care with the privacy curtain only halfway closed and the window curtains open. Resident 2 was able to make decisions and expressed feeling embarrassed and unsafe when privacy was not maintained. Resident 3, with severe cognitive impairment and requiring assistance for ADLs, was observed naked during care with the privacy curtain only partially closed. Resident 4, also with severe cognitive impairment and requiring maximum assistance, was observed fully exposed while the privacy curtain was only halfway closed during cleaning. Interviews with the CNAs involved confirmed their awareness of the importance of closing curtains to maintain resident privacy and dignity. Additional interviews with nursing staff, including an LVN and an RN, reiterated the facility's expectations for privacy during care, such as closing doors and curtains and knocking before entering. Review of facility policies confirmed the requirement to promote and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Monitor and Supervise Resident with Wandering Behavior
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and moderate cognitive impairment, who was known to wander and required substantial assistance with activities of daily living, was not adequately monitored during the night shift. This resident entered another resident's room at approximately 4:00 a.m. and became trapped between beds and curtains while in a wheelchair. The incident was discovered after the roommate heard noises and alerted staff, who then found the wandering resident in the room. Documentation and interviews confirmed that the resident's wandering behavior was not monitored or recorded during the relevant shift, despite care plan interventions and facility policy requiring such monitoring for residents at risk of unsafe wandering. The resident whose room was entered had intact cognition and required supervision or assistance with daily activities. He reported the incident as a grievance, expressing concerns about privacy and safety. Staff interviews acknowledged awareness of the wandering behavior and the importance of supervision, especially at night when confusion can increase. Facility policies reviewed indicated that staff should identify and monitor residents at risk for unsafe wandering and provide supervision based on assessed needs, but these procedures were not followed in this case.
Failure to Monitor for Bleeding in Resident on Anticoagulants
Penalty
Summary
Facility staff failed to monitor a resident for signs and symptoms of bleeding and bruising while the resident was receiving both aspirin and Eliquis for stroke prophylaxis. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and lacked capacity to make medical decisions, was identified as high risk for bleeding and bruising due to these medications. The care plan specifically required staff to monitor and document any signs of bleeding every shift. Despite these requirements, a review of the Medication Administration Record for the month showed that staff did not document monitoring for bleeding or bruising between the first and twenty-fourth of the month. The Director of Nursing confirmed that the facility did not actively monitor the resident for adverse effects related to anticoagulant therapy, which was contrary to both the resident's care plan and the facility's own anticoagulation protocol.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed multiple deficiencies related to the labeling and storage of medications in the East Medication Cart. Specifically, an opened vial of latanoprost eye drops and an opened fluticasone/salmeterol inhaler were found without labeled open dates, affecting two residents. Additionally, an opened Lantus insulin pen was also found without an open date. These medications require labeling with the date of opening according to manufacturer instructions to ensure they are not used past their recommended period of effectiveness. Further, lorazepam oral solution and gabapentin oral solution, both prescribed to a resident, were found stored at room temperature instead of in the refrigerator as required by the manufacturer. The LVN interviewed confirmed that these medications should have been refrigerated and acknowledged that a dose of gabapentin had been administered that morning after it had not been properly stored. The facility's policy and procedure on medication labeling and storage, revised in February 2023, requires medications to be stored under proper temperature controls and labeled with expiration dates when applicable.
IV Catheter Insertion Date Not Labeled on Resident's Dressing
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, hypokalemia, hyperlipidemia, and vitamin D deficiency was observed receiving intravenous (IV) fluids through a catheter inserted in the left wrist. The IV catheter's outer dressing did not display the date of insertion, as required by facility policy. The resident had severely impaired cognition and was unable to make medical decisions independently. Documentation in the resident's chart confirmed an order for a new IV catheter, but there was no indication that the date of insertion was labeled on the catheter dressing. During interviews and observations, a registered nurse confirmed that RNs are responsible for all aspects of IV care, including documentation and labeling. The nurse acknowledged the absence of the date on the IV catheter and stated uncertainty about why it was missing. Facility policy specifies that after taping the IV catheter in place, a label with the date of insertion should be applied to the catheter dressing. The lack of a date could impact the ability of staff to determine when the IV site should be changed.
Failure to Monitor Oxygen Saturation Every Shift for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that a resident who was dependent on supplemental oxygen had their oxygen saturation (O2 sat) levels checked every shift as ordered by the physician. Observation showed the resident was on 2 liters per minute of oxygen via nasal cannula. Record review revealed that the resident had diagnoses including dependence on supplemental oxygen, cardiomegaly, and a history of myocardial infarction, and was unable to make medical decisions. The resident's orders specified that O2 sat should be monitored every shift to maintain levels at 92% or above, with instructions to titrate oxygen and notify the physician if levels fell below 92%. Review of the resident's O2 sat documentation for the month showed that O2 sat levels were not being checked every shift, with several days in April lacking any recorded measurements. During an interview, an LVN confirmed that the required monitoring was not consistently performed and acknowledged that without regular monitoring, staff would not know if the resident's oxygen needs were being met or if further interventions were necessary. The facility's policy on oxygen administration also required assessment of vital signs and O2 sat while the resident was receiving oxygen therapy.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that residents in multiple rooms, specifically Rooms 6, 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29, had the required minimum living space of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. Observations revealed that some rooms, such as Room 26, contained four beds, and a review of the Client Accommodation Analysis confirmed that these rooms did not meet the minimum square footage requirements. The facility's own Room Variance Waiver request letter acknowledged that these rooms fell short of the required space. During an interview, the Administrator stated there had been no complaints from residents about the room sizes and that staff ensured residents could maneuver wheelchairs, but also acknowledged that the limited space could potentially make it difficult for staff to provide care.
Failure to Provide Ordered Pain Management for Resident
Penalty
Summary
A resident with a history of polyneuropathy, repeated falls, and diabetes mellitus was admitted to the facility and had an active order for acetaminophen 1000 mg by mouth every 6 hours as needed for severe pain, specifically for pain rated between 7/10 and 10/10. The resident was assessed as able to express needs and had no impairment in upper or lower extremities. On multiple occasions, the resident reported pain at a level of 7/10, particularly after being struck under the left eye by another resident. Despite the resident's repeated reports of severe pain, documentation on the Medication Administration Record (MAR) showed that no pain medication was administered during four nursing shifts when the resident reported pain at the threshold specified in the physician's order. Both the LVN and the DON confirmed during interviews and record reviews that the pain was documented but not treated according to the standing order. Facility policies and procedures required that medications be administered in accordance with prescriber orders and that staff identify and address residents' pain. However, the staff failed to provide the ordered pain management, resulting in the resident experiencing unrelieved pain that had the potential to interfere with activities of daily living.
Failure to Label Wound Dressings as per Policy
Penalty
Summary
The facility failed to ensure that wound dressings for two residents were labeled with the nurse's initials, time, and date, as required by the facility's policy. Resident 1, who had a stage 4 pressure ulcer, quadriplegia, and diabetes mellitus, was observed with unlabeled dressings on the left forearm and gastrostomy site. During an interview, an LVN admitted to not labeling the dressings and was unsure of the facility's policy regarding labeling. Similarly, Resident 2, who also had a stage 4 pressure ulcer and severe cognitive impairment, was found with unlabeled dressings on the sacro coccyx and gastrostomy site. Another LVN confirmed that they did not label the dressings with the required information. The Director of Nursing acknowledged that the facility's policy, which mandates labeling wound dressings with the nurse's initials, time, and date, was not followed. The policy, dated 2001, was intended to provide guidelines for care to promote wound healing. The failure to adhere to this policy had the potential to result in wound dressings not being changed, which could lead to wound infections and delayed healing.
Failure to Implement Enhanced Standard Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Standard Precautions (ESP) policy, which is designed to reduce the transmission of multi-drug resistant organisms (MDROs) by requiring healthcare workers to don personal protective equipment (PPE) such as gowns and gloves when providing care to residents at high risk for MDRO transmission. This deficiency was observed during wound care for two residents, both of whom had physician's orders for wound care due to pressure ulcers. The failure to use PPE as required by the facility's policy had the potential to result in the transmission of disease-causing organisms and delay the wound healing process for the affected residents. For Resident 6, who was admitted with diagnoses including muscle weakness, unspecified dementia, and quadriplegia, the facility's Licensed Vocational Nurse (LVN) 1 was observed performing wound care on the resident's left heel without wearing an isolation gown, despite an ESP sign being posted outside the resident's room. The resident had a physician's order for daily wound care on a Stage 3 pressure ulcer on the left heel, which required specific dressing and antiseptic procedures. LVN 1 acknowledged not using a gown, which was a precaution to minimize bacterial transmission to the wound. Similarly, for Resident 7, who had multiple unstageable pressure ulcers and chronic kidney disease, LVN 2 was observed performing wound care on the resident's sacrococcyx and left lateral malleolus wounds without wearing an isolation gown, despite the presence of an ESP sign. The resident's treatment administration record indicated daily wound care orders for these Stage 4 pressure injuries. LVN 2 admitted to not wearing the required gown before entering the room, which was necessary to prevent infection transmission. The Director of Nursing confirmed that ESP precautions should be used during wound dressing changes and for residents with a history of MDROs, emphasizing the importance of using PPE to prevent infection transmission during close contact activities.
Failure to Separate Clean and Soiled Linens in Laundry Room
Penalty
Summary
The facility failed to ensure clean linens were not placed near the facility's washing machines where dirty and soiled clothing was stored. During an observation in the facility's laundry room, 11 linen carts filled with clean linen were found placed alongside three washing machines with dirty linen washing inside. This practice was confirmed by the Housekeeping Supervisor, who acknowledged that having clean linen close to the washing machines with soiled linen could put residents at risk of infection and could spread throughout the facility. The Administrator also confirmed that the 11 carts had clean linen stored on them and should have been separated from the dirty clothing. The Administrator stated that the dirty linen was possibly soiled and could cause cross-contamination to the clean linen. The facility's policy and procedure on laundry and linen, dated January 2014, indicated that clean linen should remain hygienically clean and be kept separate from soiled linen to prevent environmental contamination. However, this policy was not followed, leading to the observed deficiency.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure staff promoted dignity while assisting Resident 56 during meals. Specifically, a Certified Nursing Assistant (CNA) was observed standing over Resident 56 and not maintaining face-to-face eye contact while assisting with the meal. This action was confirmed by the CNA, who acknowledged that standing could potentially make the resident feel rushed and affect their dignity. Interviews with other staff members, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), corroborated that assisting residents with meals should be done at eye level to promote dignity and comfort. Resident 56 also expressed a preference for staff to sit down while assisting with meals, indicating discomfort when staff stood over them. Resident 56, who has diagnoses including epilepsy, chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and major depressive disorder, was admitted to the facility on a specified date. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and dependence on staff for activities of daily living (ADLs). The facility's policy and procedure on dignity, dated February 202, emphasized the importance of providing a dignified dining experience. The failure to adhere to this policy was identified as a deficiency that could potentially impact the resident's sense of well-being and self-worth.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party (RP) was informed in advance about the risks and benefits of psychoactive medication. Specifically, Resident 56, who had diagnoses including epilepsy, COPD, schizoaffective disorder, and major depressive disorder, was administered Seroquel without documented informed consent. The resident had a moderate cognitive impairment and was dependent on staff for activities of daily living. Despite these conditions, there was no informed consent found in the resident's medical chart for the psychoactive medication prescribed and administered starting from 11/13/2024. Interviews with the facility's staff, including an LVN, an RN, and the Director of Nursing, confirmed that informed consent is required before administering psychoactive medications. The staff acknowledged that the absence of informed consent could lead to residents taking medications without being aware of the side effects, risks, and benefits. The facility's policy and procedure on informed consent, dated 3/23/2015, also indicated that documentation of informed consent is necessary before initiating the administration of psychotherapeutic drugs. However, this policy was not followed in the case of Resident 56.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for Resident 6, who was admitted with diagnoses including Type 2 diabetes mellitus, heart failure, and anxiety disorder. Resident 6, who had moderate cognitive impairment and was dependent on staff for activities of daily living, was found to have a room with chipping paint and visibly soiled walls. During an observation and interview, Resident 6 expressed dissatisfaction with the dirty walls. The Maintenance Supervisor and Housekeeping Supervisor both acknowledged the poor condition of the room, noting that it was not acceptable and could potentially pose an infection control issue. The Director of Nursing also confirmed that the room should be maintained in a homelike environment and that the current state could affect the resident's dignity and mood. The facility's policies and procedures were reviewed, revealing that walls, blinds, and window curtains in resident areas should be cleaned when visibly contaminated or soiled, and that maintenance service should ensure the building is in good repair and free from hazards. Despite these policies, the facility did not adhere to them, resulting in the deficient practice. The failure to maintain a clean and homelike environment for Resident 6 had the potential to expose the resident to dirt, harsh chemicals, infection, and accidents.
Inaccurate MDS Assessment for Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment regarding the pneumococcal vaccine for one of five sampled residents. Resident 75, who had diagnoses including end-stage renal disease, diabetes mellitus type 2, and heart failure, was not eligible to receive the pneumococcal vaccine according to their immunization history. However, the MDS assessment incorrectly indicated that the vaccine was not up to date and had been offered and declined. The MDS Nurse confirmed that the assessment was inaccurate and should have been coded as 'not eligible' instead of 'declined.' There was no documentation in Resident 75's clinical records to support that the vaccine was offered and declined. The facility's policy and procedure titled 'Certifying Accuracy of the Resident Assessment' requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion. The MDS Nurse acknowledged the importance of having an accurate assessment, as it affects the care of residents. The failure to accurately assess and document Resident 75's immunization status had the potential to result in inappropriate care and services for the resident.
Failure to Complete and Resubmit PASRR Level I Screening for Resident with New Psychosis Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASRR) Level I screening and refer Resident 22 for a PASRR Level II evaluation after a new diagnosis of psychosis. Resident 22, who was originally admitted and later readmitted to the facility, had diagnoses including psychosis and major depressive disorder. A review of Resident 22's records indicated that the resident was receiving Risperdal for psychosis and did not have the capacity to understand and make decisions. However, the PASRR Level I screening submitted by the facility did not reflect the new diagnosis or the use of psychotropic medication, and the case was closed without a Level II evaluation being required. During an interview and record review, the Business Office Manager (BOM) acknowledged that she did not complete or resubmit the PASRR Level I screening because she was unaware of Resident 22's new diagnosis of psychosis and the initiation of Risperdal. The BOM also stated that there was no system in place for the nursing staff to communicate new mental illness diagnoses to the business office. The facility's policy indicated that all residents with newly evident or possible serious mental disorders should be referred to the state mental health authority for a PASRR Level II evaluation, but this was not done for Resident 22.
Failure to Initiate Care Plan for RNA Services
Penalty
Summary
The facility failed to initiate a care plan for Restorative Nursing Assistant (RNA) services for one resident, identified as Resident 74. Resident 74 was admitted with diagnoses including ataxia, muscle weakness, repeated falls, and cardiomegaly. The resident was assessed to be cognitively intact and required supervision with transferring, dressing, and toilet use. Physician orders indicated that Resident 74 should receive RNA services for ambulation with a front-wheel walker daily, five times a week as tolerated. However, a review of the medical record revealed that no RNA care plan was initiated for Resident 74. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that care plans are essential for providing guidance, interventions, and goals for residents. The LVN acknowledged that the absence of a care plan could result in not providing necessary and quality care. The DON emphasized that care plans should be initiated on admission, during changes in condition, and throughout the resident's stay. The facility's policy and procedures also indicated that care plans should include measurable objectives and timeframes to maintain the resident's highest practicable well-being.
Failure to Revise Care Plan for Back Brace
Penalty
Summary
The facility failed to ensure that Resident 43 had a revised care plan to implement an order for a back brace, which was prescribed for support due to low back pain. The resident was initially admitted with diagnoses including low back pain, muscle spasm, and myalgia. Despite a physician's order for a back brace on 3/25/2024, the care plan was not updated to reflect this new intervention. The care plan, last updated on 8/26/2021, did not include the necessary revisions to address the resident's current needs for back support. During interviews and record reviews, both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the care plan should have been revised to include the back brace. The facility's policy and procedure on comprehensive person-centered care plans emphasize the importance of updating care plans as residents' conditions change. The failure to revise the care plan placed Resident 43 at risk for inadequate back support, potentially leading to immobility, unsteady gait, and increased back pain.
Failure to Provide Adequate Oral Hygiene
Penalty
Summary
The facility failed to provide adequate oral hygiene for Resident 92, who was unable to perform activities of daily living independently. Resident 92, who had diagnoses including cerebral infarction with hemiplegia and hemiparesis, hypertension, and diabetes mellitus, was observed with thick dried yellowish particles on her mouth and tongue. The resident was totally dependent on staff for oral hygiene, as indicated in her Minimum Data Set and Treatment Worksheet. Despite the care plan specifying that oral care should be provided every shift and as needed, this was not done, as confirmed by the Director of Staff Development (DSD) and the Director of Nursing (DON). The DSD acknowledged that it was her responsibility to ensure CNAs provided oral hygiene, and admitted that Resident 92 had not received proper oral care since her readmission to the facility. During an observation and interview, Certified Nursing Assistant 5 (CNA 5) noted that Resident 92 was under hospice care and was on nothing by mouth (NPO). The DSD confirmed the presence of thick dried, crusty yellowish substance on Resident 92's mouth and tongue, indicating poor oral hygiene. The DON stated that failing to provide good oral hygiene put Resident 92 at risk for an oral infection and acknowledged that it would be embarrassing for the facility if family members saw the resident in such a condition. The facility's policy on Activities of Daily Living, dated March 2018, mandates that residents unable to carry out these activities independently should receive necessary services to maintain good personal and oral hygiene, which was not adhered to in this case.
Failure to Provide Preferred Activities for Resident
Penalty
Summary
The facility failed to provide Resident 3 with her preferred activity of staying in the dining recreation area to participate in group activities. Resident 3, who has diagnoses including cerebral infarction with hemiplegia and hemiparesis, diabetes mellitus, and epilepsy, expressed a desire to attend group activities and socialize with other residents. Despite being awake, alert, and able to make her needs known, Resident 3 was observed in bed on multiple occasions and stated she felt bored in her room. The facility's staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that there was no reason for Resident 3 not to be up in a reclining wheelchair and participate in group activities. However, the CNA mentioned that Resident 3 was not scheduled to get up in a reclining wheelchair due to a limited supply of such wheelchairs. The Activity Director acknowledged that Resident 3 enjoys group and mental activities and noted her absence from the dining recreation area. The Director of Nursing (DON) emphasized that it is the facility's responsibility to honor and follow each resident's activity preferences. The facility's Policy and Procedure on Activity Programs, dated June 2018, states that activities should be designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident based on a comprehensive resident-centered assessment. The failure to provide Resident 3 with her preferred activities could potentially lead to a decline in memory, depression, and self-isolation, as noted by the Activity Director.
Failure to Apply Hand Roll as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a limited range of motion was provided with a left hand roll as ordered by the physician. Resident 22, who had diagnoses including osteoarthritis, contractures, and dementia, was observed without the prescribed left hand roll on multiple occasions. Instead, the hand roll was incorrectly applied to the resident's right hand. This error was confirmed during interviews with the Restorative Nursing Assistant (RNA) and the Occupational Therapist (OT), who both acknowledged the mistake and the importance of applying the hand roll to the left hand to prevent further contractures. The resident's care plan and physician's orders clearly indicated the need for a left hand roll to maintain joint integrity and prevent further contractures. Despite these directives, the RNA was unaware of the correct application site and had been placing the hand roll on the right hand. The facility's policies on splinting and restorative nursing services emphasized individualized, resident-centered care, but these were not followed in this instance, leading to the potential for further decline in the resident's range of motion and worsening of contractures.
Failure to Ensure Hemodialysis Emergency Kit Availability and Communication of Fluid Restriction
Penalty
Summary
The facility failed to ensure a resident who received hemodialysis (HD) received treatment in accordance with standards of practice. Specifically, the facility did not ensure that the HD emergency kit (E-Kit) was always available at the bedside for safety measures in case of HD complications. During observations, it was noted that the E-Kit, which should contain tape, gauze, alcohol swab, dressing, and kerlix roll, was not present at the resident's bedside. This was confirmed by Licensed Vocational Nurse (LVN) 6, who acknowledged the absence of the E-Kit and stated it should be readily visible and accessible at all times in case of emergency bleeding. The Director of Nursing (DON) also confirmed that the E-Kit is used to control bleeding in emergencies and should be available at the bedside at all times. Additionally, the facility failed to communicate to the resident's physician regarding the recommendation from the dialysis treatment center staff to limit the resident's fluid restriction to 32 ounces per day. The resident's Dialysis Communication Record indicated this recommendation, but there was no documentation that the physician was notified. The Registered Nurse (RN) and the Registered Dietitian (RD) both confirmed that they were unaware of the recommendation, and the RD stated that the resident was currently on a 1200 cc fluid restriction per day. The facility's policy and procedure indicated that recommendations from the dialysis unit should be promptly communicated with the primary care physician to ensure necessary care and services, which was not followed in this case.
Failure to Label Medications with Open Dates and Follow Manufacturer's Guidelines
Penalty
Summary
The facility failed to ensure that two medications were labeled with open dates for two residents, Resident 13 and Resident 77, and did not follow the manufacturer's guidelines for budesonide inhalation suspension for Resident 77. Resident 13, who was admitted with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen, was prescribed Spiriva hand inhaler. During an observation, it was found that the Spiriva hand inhaler did not have a documented open date. Similarly, Resident 77, who was admitted with acute and chronic respiratory failure with hypoxia and a history of nicotine dependence, was prescribed budesonide inhalation suspension. The budesonide inhalation suspension also lacked a documented open date, and the manufacturer's guidelines for using the medication within two weeks of opening the foil were not followed. Licensed Vocational Nurse 1 (LVN 1) confirmed that the medications did not have open dates and stated that it is necessary to write an open date on the medication package to ensure the medication's potency and adherence to the manufacturer's guidelines. The Director of Nursing (DON) reiterated the importance of documenting open dates to prevent the use of expired or ineffective medications. The facility's policy and procedure for administering medications also required that the expiration or beyond-use date be checked prior to administration and that the date of opening be recorded on multi-dose containers.
Failure to Provide Physician-Ordered Back Brace
Penalty
Summary
The facility failed to ensure that a resident (Resident 43) received a back brace ordered by the physician to alleviate back pain. Resident 43 was initially admitted with diagnoses including low back pain, muscle spasm, and myalgia. Despite a physician's order dated 3/25/2024 for a back brace, the resident did not receive it. During an interview on 4/18/2024, Resident 43 confirmed not having received the back brace and expressed that the staff had not updated them about the order. Observations and interviews with staff, including a CNA and a PT, confirmed that the back brace was not available and had not been ordered by the facility, despite the physician's order being medically justified. The PT noted that the back brace should have been provided within 72 hours of the order to help improve the resident's quality of life and alleviate back pain. Further interviews with the DON revealed that there was a lack of communication between the nursing staff and physical therapists regarding the physician's order for the back brace. The facility's policy and procedure on specialized rehabilitative services, dated 7/2016, indicated that therapeutic services should be provided upon the written order of the resident's attending physician. The failure to provide the back brace as ordered had the potential to increase Resident 43's back pain, highlighting a significant lapse in the facility's adherence to its own policies and procedures.
Failure to Offer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, placing the resident at higher risk of acquiring pneumonia. The resident, who had end-stage renal disease, diabetes mellitus type 2, and heart failure, was admitted and readmitted to the facility. Despite having the capacity to understand and make decisions, the resident's Minimum Data Set indicated that the pneumococcal vaccine was not up to date. The Infection Preventionist Nurse reviewed the resident's immunization history and incorrectly stated that the resident was not eligible for the vaccine due to age, without documenting any offer, decline, or administration of the vaccine in the clinical records. The facility's Policy and Procedure for Pneumococcal Management, which recommended the vaccine for individuals with certain long-term health problems, was not followed. The Infection Preventionist Nurse acknowledged that the resident was eligible for the vaccine based on the facility's policy and that the resident would be more susceptible to developing pneumonia without it. The Centers for Disease Control and Prevention also recommend the pneumococcal vaccine for people with certain medical conditions, further highlighting the oversight in the resident's care.
Non-Compliant Room Sizes
Penalty
Summary
The facility failed to ensure that 17 out of 41 resident rooms met the required square footage per resident, with multi-resident rooms measuring less than 80 square feet per resident and single-resident rooms measuring less than 100 square feet. During a facility tour, rooms 6, 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29 were observed and measured to be out of compliance. The Administrator acknowledged the non-compliance but stated that resident care had not been affected. A waiver request had been submitted previously, indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with significant mobility impairments, resulting in a serious injury. The resident, who had quadriplegia, contractures, and aphasia, required assistance from two or more staff members for activities of daily living (ADLs) such as mobility, toileting hygiene, showering, and personal hygiene, as indicated in their Minimum Data Set (MDS). However, the care plan did not specify the need for two-person assistance, and staff were not consistently following this requirement. This oversight led to a Certified Nurse Assistant (CNA) providing care alone, during which the resident sustained a right upper arm fracture that required hospitalization for evaluation and treatment. The incident was discovered when a CNA noticed a bruise on the resident's right upper arm and reported it to a Licensed Vocational Nurse (LVN). Subsequent assessments and an X-ray confirmed the fracture. Interviews with staff revealed that the CNA had been performing ADLs alone, contrary to the MDS requirements. The Director of Nursing (DON) acknowledged that all total care residents should be assisted by two staff members to prevent injuries and was unaware that this protocol was not being followed. The facility's policies and procedures emphasized the importance of safety, supervision, and adequate assistance to prevent accidents. However, the care plans did not include specific interventions to ensure two-person assistance, and staff were not adequately trained or monitored to follow this protocol. This failure to adhere to established safety measures directly contributed to the resident's injury, highlighting a significant lapse in the facility's duty to provide a safe environment for its residents.
Failure to Timely Report Suspected Abuse and Injury
Penalty
Summary
The facility failed to follow its Administrative Manual titled, Elder/Dependent Abuse, which required reporting any allegations of abuse or incidents resulting in serious bodily injury to the State Survey agency immediately, but not later than two hours. This failure was observed in the case of a resident who sustained a baseball-sized bruise and a non-displaced fracture on her right upper arm. The resident, who had quadriplegia, contractures, and aphasia, was unable to move her body and extremities without assistance. The incident was reported to the Director of Nursing (DON) approximately 20 minutes after it was discovered, but the State Survey Agency was not notified until the following day, resulting in a delay of over 24 hours from the time of discovery. The resident's care plan did not include specific interventions for two or more persons to assist with mobility, despite the resident's need for such assistance as indicated in her Minimum Data Set (MDS). Additionally, the care plan lacked safety measures to prevent injuries, even though the resident was known to bruise easily due to the use of blood thinners. Interviews with staff revealed that the injury was suspicious given the resident's inability to move independently, and the delay in reporting the incident to the State Survey Agency hindered a timely investigation by the California Department of Public Health (CDPH).
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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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