San Joaquin Nursing Center And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 3601 San Dimas, Bakersfield, California 93301
- CMS Provider Number
- 056294
- Inspections on file
- 74
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at San Joaquin Nursing Center And Rehabilitation Cent during CMS and state inspections, most recent first.
The facility failed to keep the smoking area free of accident hazards when a gap in the pavement repeatedly caught the wheels of residents’ wheelchairs. Multiple alert and oriented wheelchair users reported that their chairs became stuck on the gap, with one describing it as a speed bump and another calling it a fall hazard. During an on-site observation, the Director of Maintenance measured the gap at 0.75 inches wide, and the Activities Director, who is responsible for monitoring residents in the smoking area, acknowledged the need to ensure wheelchairs do not get caught. This condition conflicted with the facility’s written policy to keep the environment as free from accident hazards as possible.
A resident who was admitted after neck surgery did not have a required follow-up appointment with their surgeon scheduled, despite clear instructions in the medical record and care plan. Staff interviews and record reviews confirmed that social services did not coordinate or document the referral as required by facility policy, resulting in a delay in post-surgical care.
A resident with impaired cognition and a need for assistance with personal care was observed with long, dirty fingernails and multiple skin scratches. Staff confirmed that the resident's care plan required nails to be kept short and clean to prevent infection and injury, but this intervention was not followed, contrary to facility policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
A CNA and a housekeeping staff member did not wear required PPE when entering the room of a resident on contact precautions for ESBL and VRE, despite posted instructions. Additionally, an LVN failed to perform hand hygiene between glove changes during suprapubic catheter care for a resident, contrary to facility policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with moderately impaired cognition was found to have a low air loss mattress installed incorrectly, with air hose connectors at the head of the bed, resulting in the resident being struck in the head. The resident also used a facility-provided wheelchair with cracked and peeling arm rests, one of which was covered in duct tape, making proper sanitation impossible. Staff confirmed both the improper mattress setup and the unsanitary condition of the wheelchair.
Wound treatments were not completed as ordered for three residents, with multiple missed treatments and incomplete documentation on the TAR. Additionally, two residents did not receive required weekly wound assessments, with several assessments missing measurements or left incomplete. Staff interviews confirmed that treatments and assessments were not performed as required, and facility policies for wound care documentation and assessment were not followed.
A background check for an LVN was not completed prior to employment, as required by facility policy. The check was finalized more than a month after the hire date, and this was confirmed by the DSD during record review and interview.
The facility failed to follow CDC infection control practices, as a CNA entered a resident's room under Enhanced Barrier Precautions without PPE and did not perform hand hygiene. Additionally, two residents did not receive hand hygiene assistance before meals, contrary to facility policy.
The facility failed to follow physician orders for several residents, including not conducting necessary blood work for a resident with epilepsy, not providing compression stockings for a resident at risk of DVT, and administering IV medications at incorrect rates for multiple residents. These oversights could lead to significant health risks.
A registered nurse in a facility failed to maintain competency in calculating IV medication flow rates, leading to incorrect infusion rates for several residents. The nurse relied on the internet for calculations and had not received recent competency training. The Director of Nursing confirmed the lack of specific training for IV flow rate calculations, despite the facility's policy requiring accurate regulation of medication flow.
The facility failed to follow its medication handling and security procedures, as observed with LVNs discarding medications improperly and leaving a medication cart unlocked. Additionally, Controlled Drug Records lacked necessary nurse signatures, indicating a lapse in documentation and handling of controlled substances.
A resident was found to be self-administering eye drops without a physician's order or an IDT assessment to determine his capability to do so safely. The resident had been using the eye drops for five years post-surgery, with some nurses aware of this practice. However, there was no documentation in the medical records or care plan, and the facility's policy on self-medication administration was not followed.
The facility failed to ensure an advance directive was offered and completed for a resident. During a review, the MDS Coordinator could not find the resident's completed AD in the medical record, despite acknowledging it should be there. The facility's policy requires that residents are informed of their rights to make medical decisions, including formulating advance directives, and that care plans align with these preferences. The absence of the AD indicates non-compliance with this policy.
The facility failed to notify the ombudsman of hospital transfers for two residents, as required by their policy. The Social Services Director confirmed the lack of documentation for these notifications, which could result in the residents not having an advocate to inform them of their rights and options.
A facility failed to accurately assess and document urine output for a resident with a urostomy, resulting in the physician being unaware of accurate measurements. The resident self-catheterizes as needed, but documentation was inconsistent, with zero totals recorded for urine output over several days. The facility lacked a policy for urine intake and output, leading to inadequate documentation procedures.
The facility failed to complete discharge summaries accurately for two residents, potentially impacting their follow-up care and safety. One resident, with multiple diagnoses including Parkinsonism and COPD, lacked essential information in their discharge summary, such as physician and pharmacy contact details, and an assessment of their ability to perform care at home. Another resident, admitted with a femur fracture and other conditions, also had an incomplete discharge summary missing similar critical information and was not signed by the resident.
A resident did not receive appropriate foot care, as their thick and yellowish toenails were not referred to podiatry despite observations by staff. The facility's policies required such referrals, but there was no documentation of a referral or physician notification, leading to a deficiency.
The facility did not complete required Performance Evaluations for two CNAs, as per their policy. CNA 1 and CNA 5, hired in early 2023, lacked evaluations in their files, contrary to the policy requiring annual reviews. This oversight could leave staff unaware of necessary improvements in patient care.
The facility failed to maintain a medication error rate below 5%, with errors involving incorrect IV antibiotic flow rates for several residents. The flow rates were set higher than prescribed, leading to faster infusion rates. RN 1 and the DON acknowledged the discrepancies, and the facility's policies emphasize adherence to prescriber orders, which was not followed.
A resident expressed discontent after receiving peanut butter and jelly sandwiches for every meal over seven days due to the facility's failure to evaluate and accommodate his food preferences. Despite the resident's requests for alternatives, no changes were made, and the Certified Dietary Assistant had not assessed the resident's preferences. The Registered Dietitian updated the preferences, but the facility did not provide an updated meal ticket, violating the policy on menu alternatives.
A facility failed to document a resident's edema in their medical records, as observed during a survey. The resident's swollen legs and feet were not recorded in the Weekly Nursing Summary over several weeks, and the Minimum Data Set Coordinator confirmed the absence of documentation. Staff interviews indicated that changes in condition should be included in the summary, but this was not done. The facility's policy requires complete and accurate documentation, which was not adhered to in this case.
The facility failed to document verbal acknowledgment of the Binding Arbitration Agreement (BAA) from family representatives of two residents, as required by its policy. Interviews confirmed that while the representatives claimed to understand the BAA, the facility did not document this verbal acknowledgment in the medical records, contrary to policy requirements.
The facility failed to maintain an effective QAPI Program, with staff unaware of the plan and process improvement projects. The Administrator and DON could not provide evidence of data-driven interventions for rehospitalization, and the facility lacked documentation and specific quality indicators.
A resident was readmitted with a pressure injury (PI) on the right buttock, but the facility failed to develop a care plan for this condition. Despite having a physician's order for daily application of Medihoney wound gel, there was no documented care plan. Interviews with the DON and TN confirmed the oversight, which was against the facility's policy requiring a baseline care plan upon admission.
A resident admitted with pain due to an orthopedic prosthetic device and osteoarthritis did not receive appropriate pain management. The resident's Lidocaine patch was not administered as it was unavailable, and although Acetaminophen was given, the pain level increased. The LVN did not contact the physician for additional pain management, contrary to the facility's policy, which requires immediate communication if pain is not controlled.
The facility did not complete baseline care plans within 48 hours for three residents. The Social Services and Rehabilitative Services sections were delayed, with one resident's Activities section completed 21 days post-admission. The DON confirmed the requirement for completion within 48 hours, as per facility policy.
A resident in the facility exhibited behaviors such as refusal of care, yelling, and grabbing, but did not receive necessary behavioral health services. The Social Services Director was unaware of these behaviors, and there was no documentation of services provided. The facility's policy requires behavioral health services based on a comprehensive assessment, but this was not followed.
A resident's right to receive a phone call was violated when a facility receptionist refused to transfer a call due to lack of caller information, citing HIPAA. The resident, needing assistance and using a wheelchair, had no phone in her room. The facility lacked a protocol for handling such calls, despite policies ensuring phone access and privacy.
A facility failed to ensure a resident received necessary services for pressure injuries due to non-compliance with turning and repositioning. Despite the resident's understanding of the risks and benefits, the treatment nurse documented the non-compliance but did not ensure it was included in the active care plans. The Director of Nursing confirmed the absence of a non-compliance care plan, contrary to the facility's policy on comprehensive care plans.
A resident frequently pulled out his G-Tube, requiring multiple emergency room visits for re-insertion. Despite the resident's diagnosis of Gastrostomy Status, the facility did not develop an individualized care plan or hold an interdisciplinary team meeting to address the issue, contrary to their policy requiring a comprehensive care plan within seven days of the MDS assessment.
A resident, who was cognitively intact, reported neglect due to delayed medication administration and called the police. Despite the serious allegation, the facility did not investigate or report the incident to the CDPH, contrary to their policy. The DON stated no investigation was needed as the police found nothing.
A resident accused the facility of neglect, claiming she was not cared for or given medication. The Social Services Designee failed to follow up or provide psychosocial monitoring after the incident, as required by the facility's job description, potentially causing distress to the resident.
A resident was not informed of a room change during a hospital transfer, despite having a paid bed hold agreement. The facility converted the resident's room into a female room and moved his belongings without prior notice. Upon return, the resident was unaware of the change and expressed dissatisfaction. The facility's policy requires advance notice for room changes unless medically necessary, which was not followed in this case.
A resident with moderate cognitive impairment was not allowed to return to his previous room after a hospital stay, despite having signed a Bed-Hold and Return Agreement. The resident's belongings were packed, and he was moved to a different room without his consent, leading to feelings of distress and disrespect.
The facility failed to provide oxygen as ordered for a resident and did not provide humidified oxygen for two residents on continuous oxygen. One resident was observed with an incorrect oxygen setting, and both residents lacked humidifiers, contrary to the facility's policy.
Pavement Gap in Smoking Area Creates Wheelchair Hazard
Penalty
Summary
The deficiency involves the facility’s failure to maintain the designated smoking area free of accident hazards, specifically a gap in the pavement that interfered with wheelchair movement. During an observation and interview, two alert and oriented residents who used wheelchairs reported that their wheelchairs were caught by the pavement gap, with one resident describing it as a “speed bump” that could cause residents to fall from their wheelchairs. A third alert and oriented resident using a wheelchair also reported that his wheelchair had gotten stuck in the same pavement gap and described it as a fall hazard for wheelchair users. During a concurrent observation and interview in the smoking area, the Director of Maintenance measured the pavement gap and stated it was 0.75 inches wide. The Activities Director, who stated she was responsible for monitoring residents in the smoking area, acknowledged the need to ensure that residents using wheelchairs were not caught in the pavement gap. Review of the facility’s policy titled “Safety and Supervision of Residents,” dated July 2017, indicated that the facility strives to make the environment as free from accident hazards as possible, which was not achieved in this instance due to the unresolved pavement gap in the smoking area.
Failure to Schedule Post-Surgical Follow-Up Appointment
Penalty
Summary
The facility failed to follow its policy and procedure regarding social services referrals by not scheduling a follow-up appointment with a surgeon for a resident who had recently undergone neck surgery for a C5-6 fracture and vertebral artery stenosis. Upon admission, the resident's history and physical report clearly indicated the need for a follow-up with the surgeon within two weeks. However, review of the clinical records and interviews with staff, including the LVN, DON, and Social Services Director, revealed that no such appointment was scheduled or documented. The information necessary to arrange the appointment, including the surgeon's name and hospital, was present in the resident's medical record, but was overlooked during the admission and subsequent reviews by social services. The resident reported having inquired about the follow-up appointment with social services but confirmed that no appointment had been made since admission. The care plan also included an intervention to follow up with the surgeon as indicated, but this was not carried out. The facility's policy required social services to coordinate medical referrals and document them in the resident's record, but this process was not followed, resulting in a delay in arranging necessary post-surgical care for the resident.
Failure to Maintain Resident Nail Hygiene as Required by Care Plan
Penalty
Summary
The facility failed to ensure that a resident's fingernails were kept clean and trimmed, as required by the resident's care plan and facility policy. The resident, who had a diagnosis indicating a need for assistance with personal care and demonstrated moderately impaired cognition, required substantial to maximal assistance with personal hygiene. Observations revealed that the resident's fingernails were long and had dark debris underneath, and the resident had multiple scratches and open skin areas on both arms and abdomen. The resident reported frequent itching and a desire to have his fingernails trimmed. Staff interviews confirmed that the resident's fingernails were supposed to be kept short and clean to prevent infection and injury, especially given the resident's history of picking and scratching at his skin. The care plan specifically included interventions to keep the resident's nails short to reduce the risk of skin injury and infection. However, the care plan was not followed, as acknowledged by the Infection Control Preventionist, and the facility's policy on nail care, which requires daily cleaning and regular trimming, was not implemented for this resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Follow Contact Precautions and Hand Hygiene Protocols
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to wear the required personal protective equipment (PPE) when entering the room of a resident who was on contact precautions due to diagnoses of Extended Spectrum Beta Lactamase (ESBL) resistance and Vancomycin-Resistant Enterococci (VRE) in the urine. The resident's room had a clearly posted Contact Precautions sign instructing staff to wear a gown and gloves upon entry. During observation, the CNA was seen transferring the resident from bed to wheelchair without wearing a gown and stated she was unaware of the resident's contact precautions status. Additionally, a housekeeping staff member was observed cleaning the same resident's bed without wearing a gown, contrary to facility policy and procedure for contact isolation. In a separate incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after removing used gloves during suprapubic catheter care for another resident. The LVN cleaned the catheter insertion site, removed gloves, and donned new gloves without washing hands in between, despite facility policy requiring hand hygiene after glove removal. The LVN acknowledged the lapse during interview, and the Infection Control Preventionist confirmed that the facility's policy was not followed.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Improper Installation of Medical Equipment and Unsanitary Wheelchair
Penalty
Summary
A deficiency occurred when a low air loss mattress, intended to prevent and treat pressure injuries, was improperly installed for a resident with moderately impaired cognition. The air hose connectors were positioned at the head of the bed and left on the floor, contrary to manufacturer instructions that specify placement at the foot of the bed. The resident reported being struck in the head by the machine multiple times over a two-week period and stated that a CNA was informed but did not correct the setup. Observations by the Maintenance Director and a Licensed Vocational Nurse confirmed the improper installation and location of the air hose connectors. Additionally, the same resident was provided with a wheelchair that had a cracked and peeling right arm rest and a left arm rest covered in duct tape. The resident stated the wheelchair was received in this condition. The Maintenance Director confirmed the damage and was unable to verify if the arm rests could be sanitized. A Licensed Vocational Nurse stated that cracked and peeling arm rests should be replaced, as they cannot be properly sanitized. The facility's infection prevention and control policy requires maintaining a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases.
Failure to Complete Wound Treatments and Weekly Assessments
Penalty
Summary
The facility failed to ensure that wound treatments were completed as ordered by the physician for three residents. For one resident, wound treatments to the right upper arm, forearm, and hand were not performed on two specific dates, as indicated by blank entries on the Treatment Administration Record (TAR). For another resident, wound treatments for pressure injuries on the left iliac crest, right gluteus, and right iliac crest were not completed on five separate dates, with the TAR left blank for all wounds on those days. A third resident did not receive wound treatments for multiple wounds, including the left lateral heel, left ischium, and right medial thigh, on several dates, as evidenced by missing documentation on the TAR. Staff interviews confirmed that if the TAR was not signed, the treatment was not performed, and when the wound nurse was not present, floor nurses were responsible for completing treatments, which did not occur as required. Additionally, the facility did not complete weekly wound assessments for two residents. For one resident, several Skin & Wound Evaluations (SWE) were missing wound measurements or were left incomplete for multiple wounds, including the left iliac crest and right gluteus. Another resident's admission assessment and subsequent weekly assessments were missing wound measurements and other required documentation for multiple wounds, such as venous stasis ulcers and pressure injuries. Staff interviews confirmed that these assessments were incomplete or missing, and that weekly wound assessments should have been performed but were not. A review of the facility's policies and procedures indicated that documentation of wound care should include the date and time care was given, the name and title of the person performing the care, and all assessment data such as wound bed color, size, and drainage. The policy also required weekly risk assessments and wound assessments for residents. The observed deficiencies were due to the failure to follow these documentation and assessment protocols, as evidenced by incomplete or missing records and staff confirmations during interviews.
Failure to Complete Timely Background Check Prior to Employment
Penalty
Summary
The facility failed to follow its own policy and procedure regarding background screening investigations for new hires. Specifically, the employee file for one Licensed Vocational Nurse (LVN) showed that the background check was completed more than a month after the hire date, rather than prior to employment as required by the facility's policy. The policy states that background and criminal checks must be initiated within two days of an offer of employment and completed before the employee starts work. During an interview, the Director of Staff Development confirmed that the background check was not completed before the LVN began employment.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control practices as outlined by the CDC, specifically in the use of Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident with an infected wound on the right big toe, who was under EBP, without wearing the required personal protective equipment (PPE) such as gloves and a gown. The CNA assisted the resident in transferring from a wheelchair to a bed, making direct contact with the resident's right foot and leg. Afterward, the CNA handled another resident's food item without performing hand hygiene, despite the CDC guidelines posted outside the room that mandated cleaning hands before entering and upon leaving the room, and wearing gloves and a gown during high-contact activities like transferring and wound care. Additionally, the facility did not ensure hand hygiene was performed for two residents before their meals were served. In separate observations, two different CNAs delivered lunch trays to residents without assisting them with hand hygiene, despite the facility's policy requiring staff to provide hand wipes, sanitizer, or assist with handwashing for residents unable to do so themselves. Both CNAs acknowledged the oversight when questioned, and one resident confirmed that hand hygiene was not typically performed before meals.
Failure to Follow Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to adhere to physician orders for several residents, leading to potential health risks. Resident 10, diagnosed with epilepsy, did not have their blood work drawn monthly as ordered, which could have left the physician unaware of medication levels, increasing the risk of seizures. The nursing consultant confirmed that the necessary labs were not conducted from September 2024 to January 2025, highlighting a significant oversight in monitoring the resident's condition. Resident 26, with medical diagnoses including muscle wasting and reduced mobility, was not provided with compression stockings as ordered for DVT prophylaxis. Observations revealed that the resident was not wearing the stockings, and staff members were unaware of the requirement. The medication administration record inaccurately indicated that the stockings had been applied, suggesting a documentation error and a lack of awareness among staff about the resident's needs. For residents on IV medications, the facility failed to administer the medications at the prescribed rates. Residents 352, 351, 96, and 2 were all receiving IV antibiotics at incorrect flow rates, which could potentially affect the efficacy of the treatment and the residents' health. The facility's policy on medication administration was not followed, as the flow rates were set incorrectly, and staff were not regulating the flow as prescribed. This oversight in medication administration could lead to adverse effects on the residents' health, as noted by the RN during observations.
Failure to Maintain RN Competency in IV Flow Rate Calculation
Penalty
Summary
The facility failed to maintain competency for a registered nurse (RN 1) in calculating intravenous (IV) medication flow rates, which had the potential to result in incorrect medication dosages for residents. During observations and interviews, it was found that RN 1 was administering IV antibiotics to several residents using a flow rate controller set to open or incorrect settings, leading to faster-than-prescribed infusion rates. RN 1 admitted to using the internet to calculate flow rates and stated that she had not received any competency training on this task since nursing school two years ago. The Director of Nursing (DON) confirmed that competency training was provided for PICC line and central line procedures but not specifically for IV flow rate calculations. The facility's job description for registered nurses required mathematical skills to apply concepts such as fractions and ratios, but RN 1's competency skills checklist did not document current competency for IV medication administration. The facility's policy on infusion therapy medication administration emphasized the need for safe and accurate regulation of medication flow, which was not adhered to in this case.
Medication Handling and Security Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure for discarding and destroying medications, as observed in several instances involving Licensed Vocational Nurses (LVNs). LVN 5 was observed discarding a white pill found on the floor in a resident's room into a trash can instead of the designated pharmacy discard bin. Additionally, LVN 5 was seen tossing a blue pill into an open container on top of a medication cart, stating she would dispose of it later. Similarly, LVN 1 was observed discarding a Vitamin C tablet into a trash can instead of the pharmacy receptacle. These actions were contrary to the facility's policy, which requires medications to be destroyed in a specific manner to prevent potential drug diversion. The facility also failed to maintain proper security and documentation for controlled drugs. An unattended medication cart was found unlocked in a resident's doorway, and LVN 5 admitted to leaving it unsecured while attending to a resident. Furthermore, the Controlled Drug Records (CDR) lacked signatures from two nurses for several medications, including dronabinol and hydrocodone/acetaminophen, indicating a failure to follow the required procedure for documenting and handling controlled substances. The Director of Nursing (DON) acknowledged that the CDRs were not reviewed, and the necessary signatures were missing, which could lead to medications being unaccounted for.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 96, was clinically assessed and determined capable of self-administering medication. Resident 96 had been using eye drops, specifically an ophthalmic solution, at his bedside without a physician's order or an interdisciplinary team (IDT) assessment to confirm his ability to self-administer the medication safely. The resident reported using the eye drops for five years following eye surgery, and some nurses were aware of this practice. However, there was no documentation in the medical records or care plan to support that the resident had been evaluated for self-medication administration. The facility's policy on self-medication administration requires an IDT assessment to determine if a resident can safely self-administer medication, with documentation in the medical record and care plan if deemed appropriate. In this case, there was no IDT documentation or nursing progress notes regarding the resident's capacity to self-administer medication. Additionally, the eye drops were not stored securely, as required by the facility's policy, which mandates that self-administered medications be kept in a safe and secure place inaccessible to other residents.
Failure to Ensure Completion of Advance Directive
Penalty
Summary
The facility failed to ensure that an advance directive (AD) was offered and completed for one of the sampled residents, identified as Resident 16. During an interview and record review, the Minimum Data Set Coordinator (MDSC) was unable to locate Resident 16's completed AD in the medical record. The MDSC acknowledged that the AD should have been present in the medical record. The facility's policy and procedure on advance directives, dated 2013, requires that prior to or upon admission, residents are provided with written information about their rights to make medical care decisions, including the formulation of advance directives. Additionally, the policy states that each resident's plan of care should align with their documented treatment preferences and/or advance directive. The absence of Resident 16's AD in the medical record indicates a failure to adhere to this policy, potentially impacting the resident's healthcare wishes.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of transfers or discharges, specifically in notifying the ombudsman. This deficiency was identified during interviews and record reviews involving two residents. Resident 16 was transferred to the hospital on two occasions, and Resident 38 was transferred once. In both cases, the Social Services Director (SSD) could not find documentation that the ombudsman had been notified of these transfers, as required by the facility's policy. The facility's policy, titled 'Transfer or Discharge, Facility-Initiated,' mandates that notice of transfer should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, the SSD confirmed that there was no documentation of ombudsman notification for the transfers of Resident 16 and Resident 38. This oversight could potentially result in the residents not having an advocate to inform them of their rights and options regarding admission, transfer, and discharge.
Failure to Accurately Document Urine Output for Resident with Urostomy
Penalty
Summary
The facility failed to accurately assess and document urine output for a resident with a urostomy, leading to the physician being unaware of the resident's accurate urine output measurements. During an observation and interview, it was noted that the resident self-catheterizes as needed, but there was no bag attached to the urostomy. The resident's care plan indicated that licensed nurses should monitor urine output every shift, and the order summary report required daily total output documentation for intermittent straight catheterization. However, the medication administration record showed inconsistent documentation of the number of self-catheterizations and milliliters of urine output. Further review of the resident's voiding diary for February 2025 revealed zero totals for urine output each day from February 1st through February 12th. The facility's policy on documentation accuracy emphasized the importance of accurate clinical records for continuity of care and coordination of services. Despite this, the facility did not provide a policy for urine intake and output, indicating a lack of proper documentation procedures. This deficiency highlights the facility's failure to ensure accurate and consistent documentation of the resident's urine output, which is crucial for meeting the resident's individualized needs.
Incomplete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure the discharge summaries for two residents were completed accurately, which could potentially impact their follow-up care and safety. Resident 60, who was admitted with multiple diagnoses including Parkinsonism, muscle wasting, COPD, hepatic encephalopathy, and liver cirrhosis, requested to be discharged home to continue therapy services. However, the discharge summary for Resident 60 lacked essential information such as the contact details for the primary care physician and pharmacy, a recapitulation of the resident's stay, the discharge status, and an assessment of the resident's ability to perform required care at home. Similarly, Resident 84, admitted with a fracture of the left femur, muscle wasting, foot drop, and abnormal gait, also had an incomplete discharge summary. The summary did not include the physician's contact information, pharmacy details, a recapitulation of the resident's stay, discharge status, an assessment of the resident's ability to perform required care at home, and was not signed by the resident. These omissions were identified during interviews and record reviews with the facility's Nursing Consultant and Social Services Director, highlighting a failure to adhere to the facility's discharge summary policy.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident not being referred to podiatry for treatment of foot and toenail disorders. During an observation, the resident's toenails were found to be thick, long, and yellowish, with small scabs and redness on some toes. The resident confirmed not having seen a podiatrist. A registered nurse also observed the condition and acknowledged the need for a podiatry referral, but there was no documentation of this observation or referral in the resident's records. Further review revealed that the facility's policies required residents with foot disorders to be referred to qualified professionals, but there was no documentation of the physician being notified or a podiatry referral being made. The facility's social services policy also indicated that social services staff are responsible for making referrals and obtaining needed services, which was not done in this case. This lack of action and documentation led to the deficiency in providing necessary foot care for the resident.
Failure to Complete Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PE) for two Certified Nursing Assistants (CNAs), specifically CNA 1 and CNA 5, as required by their policy. During an interview and record review with Human Resources (HR), it was revealed that CNA 1, hired on February 6, 2023, did not have a PE completed for the last two years. Similarly, CNA 5, hired on March 15, 2023, also lacked a completed PE. The facility's policy, dated February 2023, mandates that each employee's job performance be reviewed and evaluated at least annually, with the completed evaluation sent to HR to be placed in the employee's personnel record. The absence of these evaluations indicates a failure to adhere to the facility's policy, potentially leaving staff unaware of areas needing improvement in patient care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass observation, resulting in a medication error rate of 9.26%. This was due to five medication errors observed in a sample size of 54 opportunities for error. The errors involved incorrect flow rates for intravenous (IV) antibiotic medications being administered to residents. Specifically, the flow rates for antibiotics such as Piperacillin-Tazobactam and Ceftriaxone were set higher than prescribed, leading to faster infusion rates than intended. For instance, Resident 352's IV antibiotic was set to an unmetered flow, while the label indicated it should be infused over one hour at a specific rate. Similarly, Resident 351's and Resident 96's antibiotics were also infused at rates higher than prescribed. During interviews, RN 1 acknowledged the discrepancies in the flow rates, stating that the current rates were higher than the prescribed 25 drops per minute. The Director of Nursing (DON) also confirmed that an intravenous flow rate of 40 drops per minute is too fast for residents. The facility's policy and procedure documents, dated 2019, emphasize the importance of administering medications in accordance with prescriber orders and regulating the flow of medication infusion as prescribed. However, these guidelines were not adhered to, resulting in the observed medication errors.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to evaluate and accommodate the food preferences of a resident, identified as Resident 90, which led to the resident receiving peanut butter and jelly sandwiches for every meal over a period of seven days. This situation resulted in the resident expressing discontent and anger due to the lack of variety and the quality of the meals, which were described as bland and cold. Despite the resident's requests for alternatives, no changes were made to the meal offerings, and the resident did not recall any communication with kitchen staff regarding his preferences. Interviews and record reviews revealed that the Certified Dietary Assistant, who was covering for the dietary manager, had not assessed the resident's food preferences. Although the Registered Dietitian met with the resident and updated his food preferences, the facility failed to provide an updated meal ticket reflecting these preferences. The facility's policy on menu alternatives, which requires providing equivalent nutritional substitutions for disliked foods, was not followed, as evidenced by the lack of alternative meal options for the resident.
Failure to Document Resident's Edema in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of edema in the resident's lower extremities. During an observation, the resident was noted to have swollen legs and feet, but this condition was not documented in the Weekly Nursing Summary (WNS) for several weeks. The Minimum Data Set Coordinator (MDSC) confirmed the absence of documentation regarding the edema in the WNS and stated that there was no indication that the condition was brought to anyone's attention. Interviews with staff revealed that the weekly nursing summary is supposed to include changes in the resident's condition, such as edema, in a narrative section. However, this was not done for the resident in question. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, and the Registered Nurse Job Description emphasizes the need for informative and descriptive nursing notes. The lack of documentation could potentially lead to the resident's physician being unaware of the condition and not ordering appropriate tests or medication.
Failure to Document Verbal Acknowledgment of Binding Arbitration Agreement
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Binding Arbitration Agreement (BAA) for two residents. Specifically, the Admission staff did not document a verbal acknowledgment of the BAA from the family representatives of two residents. This oversight was identified during interviews and record reviews, where it was noted that the facility's policy required a verbal acknowledgment of understanding from the resident or their representative, which was not documented in the medical records. Interviews with the family representatives of the two residents revealed that they had signed the BAA and claimed to understand the agreement without any questions or concerns. However, the Marketing Director/Admissions confirmed that the facility did not document whether the residents or their representatives verbally acknowledged or understood the BAA. The facility's policy explicitly stated that a signature alone was insufficient and required a verbal acknowledgment to be documented, which was not done in these cases.
Ineffective QAPI Program and Lack of Staff Awareness
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program for all 96 residents. During interviews, Licensed Vocational Nurses (LVNs) 3 and 4 were unaware of the QAPI plan and the facility's process improvement projects. The Administrator stated that the QAPI Committee meets monthly or quarterly, focusing on falls, rehospitalization, call lights, surveyor visits, and complaints. However, the Administrator could not identify other process improvement projects using clinical indicators apart from the CMS-required quality measures. The Director of Nursing (DON) presented the rehospitalization process improvement project, citing disease processes like diabetes, hypertension, and heart disease. However, the DON could not provide evidence of aggregate data on the number of residents monitored for these diseases, the signs and symptoms triggering the project, or other clinical indicators to monitor and determine interventions to decrease rehospitalization. The facility's policy and procedure on QAPI indicated the need for a comprehensive plan to monitor and evaluate resident care quality, but the facility lacked documentation and specific quality indicators for individual departments.
Failure to Develop Care Plan for Pressure Injury
Penalty
Summary
The facility failed to develop a care plan for a resident's pressure injury (PI) upon their readmission. The resident was readmitted with a PI on the right buttock, as noted in the Readmission Skin Assessment. Despite the presence of a physician's order for Medihoney wound gel to be applied daily for 21 days, there was no documented evidence of a care plan addressing the PI. Interviews with the Director of Nurses (DON) and the Treatment Nurse (TN) confirmed the absence of a care plan for the resident's PI. The facility's policy requires the development of a baseline care plan upon admission, which includes initial goals and physician orders. However, this was not adhered to, as the care plan was neither updated nor developed for the resident's wound, contrary to the facility's practice.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted with diagnoses including pain due to an internal orthopedic prosthetic device and unilateral osteoarthritis. Upon admission, the resident complained of a pain level of 5 out of 10. The Medication Administration Record (MAR) indicated that a Lidocaine patch, prescribed for pain, was not administered because it was not available. Although Acetaminophen was administered later for the resident's pain, the resident's pain level increased to 6 out of 10 shortly after. The Licensed Vocational Nurse (LVN) involved stated that the protocol was to assess the resident's pain and administer medication according to the physician's orders. However, the LVN did not call the physician for additional pain management orders when the resident's pain level increased. The Director of Nursing (DON) confirmed that the nurse should have contacted the physician to obtain an order for further pain management. The facility's policy on pain assessment and management emphasized the need for ongoing communication with the prescriber and immediate contact if the resident's pain was not adequately controlled.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents. For Resident 1, the Social Services and Rehabilitative Services sections of the Baseline Care Plan Person-Centered Care Planning (BCPPCCP) were completed six days after admission, and the Activities section was completed 21 days after admission. Resident 2's BCPPCCP had the Social Services section completed three days after admission and the Rehabilitative Services section four days after admission. For Resident 3, the Social Services section was completed six days after admission, and the Rehabilitative Services section was completed four days after admission. The Director of Nursing confirmed that the BCPPCCP should have been completed within 48 hours of admission, as per the facility's policy and procedure dated December 2023, which mandates a baseline care plan be developed within 48 hours and a written summary provided to the resident or their representative.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident, identified as Resident 1, which could potentially result in unmet psychosocial needs. Interviews and record reviews revealed that Resident 1 exhibited behaviors such as refusal of care, yelling, pushing, and grabbing, documented on multiple occasions. Despite these documented behaviors, the Social Services Director was unaware of Resident 1's behaviors, and there was no documentation of behavioral health services being provided to address these issues. Further investigation showed that the Minimum Data Set Coordinator acknowledged that Resident 1 should have been referred to a psychiatrist for behavioral health services. The facility's policy and procedure on Behavioral Assessment, Intervention, and Monitoring, dated 2001, mandates that residents receive behavioral health services as needed, based on a comprehensive assessment and plan of care. However, the clinical record for Resident 1 lacked documentation of such services, indicating a failure to adhere to the facility's policy.
Violation of Resident's Communication Rights
Penalty
Summary
The facility failed to honor a resident's right to receive a telephone call, resulting in a violation of the resident's communication rights. The incident involved a complainant who attempted to contact the resident with a confidential call. However, the receptionist refused to transfer the call to the resident, citing the impossibility of transferring phones. Additionally, a registered nurse (RN) confirmed that the complainant did not provide her name or phone number, and due to HIPAA regulations, the RN did not give the telephone to the resident. Observations revealed that the resident, who requires partial assistance for activities involving the lower extremities and uses a wheelchair, did not have a telephone in her room. The Director of Nursing (DON) stated that there was no specific protocol regarding who residents could speak to, and it was not the facility's business to inquire. The facility's policy indicated that telephones should be located in areas offering privacy and accommodating residents with hearing impairments or those who are wheelchair-bound, and assistance should be provided to residents needing help with telephone use.
Failure to Address Resident Non-Compliance in Care Plan
Penalty
Summary
The facility failed to ensure that a resident received the necessary services for pressure injuries to promote healing. The resident was identified as non-compliant with turning every two hours to offload pressure from the coccyx area and elevating legs to promote circulation, as documented in the interdisciplinary team skin management notes. Despite the resident's verbal acknowledgment of understanding the risks and benefits of these actions, the treatment nurse noted the non-compliance in the skin management notes but was unsure if this information was included in the active care plans accessible to certified nurse assistants. During a review of the resident's care plans, the Director of Nursing confirmed that no care plan addressing the resident's non-compliance was created. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and interventions derived from comprehensive assessments. However, the lack of a non-compliance care plan for the resident indicates a failure to adhere to this policy, potentially leading to unmet care needs.
Failure to Develop Individualized Care Plan for G-Tube Management
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who frequently pulled out his Gastrostomy Tube (G-Tube). The resident, who had a diagnosis of Gastrostomy Status, was observed to have pulled out his G-Tube on multiple occasions, as documented in the SBAR Communication and Progress Notes. These incidents occurred on several dates, including 4/30/2024, 5/3/2024, 5/8/2024, 6/6/2024, and 6/26/2024, each time resulting in the resident being sent to the emergency room for re-insertion of the G-Tube. During an interview and record review with the Director of Nursing (DON) on 8/2/2024, it was confirmed that there was no care plan in place to prevent the resident from frequently pulling out the G-Tube. Additionally, there was no interdisciplinary team meeting held to address this issue. The facility's policy and procedure on care plans, dated March 2022, requires a comprehensive, person-centered care plan to be developed by the interdisciplinary team within seven days of the completion of the required MDS assessment, which was not adhered to in this case.
Failure to Report and Investigate Allegation of Neglect
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of suspected abuse, neglect, or misappropriation for a resident who made an allegation of neglect. The resident, who was cognitively intact with a BIMS score of 13, reported that the facility was taking an excessively long time to attend to her needs, including a significant delay in receiving medication. The resident expressed concern for her safety and eventually called the police due to the lack of response from the facility staff. Despite the resident's serious allegations and the involvement of law enforcement, the facility did not conduct an investigation or report the incident to the California Department of Public Health (CDPH) as required by their policy. The Director of Nursing (DON) stated that there was no need for a care plan or investigation since the police found nothing. However, the facility's policy clearly mandates that all allegations of neglect must be reported and investigated, which was not done in this case.
Failure to Provide Psychosocial Monitoring After Allegation of Neglect
Penalty
Summary
The facility failed to provide medically related social services for a resident following an allegation of neglect. The Social Services Designee (SSD) did not follow up or provide psychosocial monitoring for the resident after the resident called the police, accusing the facility of neglecting her care and medication needs. The SSD was unaware of the incident and did not conduct a psychosocial assessment, as required by the facility's job description for the Social Services Director. This oversight had the potential to cause psychosocial distress to the resident.
Failure to Notify Resident of Room Change During Hospital Transfer
Penalty
Summary
The facility failed to provide advance notice of a room change to a resident during a three-day hospital transfer. The resident had signed a Bed-Hold and Return Agreement requesting the facility to hold his bed space during his absence. However, during the resident's hospital stay, the facility converted his room into a female room and moved his belongings to a new room without informing him. Upon his return from the hospital, the resident was unaware of the room change and expressed dissatisfaction with the new arrangement. The Director of Nursing confirmed that the resident was on a paid bed hold during his hospital stay and was not informed of the room change prior to his return. The facility's policy and procedure on room changes state that residents should be provided with advance notice unless the change is medically necessary or for the safety and well-being of the residents. The policy also states that residents have the right to refuse a room change if it is solely for the convenience of the staff. In this case, the facility did not adhere to its policy, resulting in the resident being unaware of the room change until his return.
Resident's Right to Return to Previous Room Not Honored
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not allowing him to return to his previous room after a hospital stay. The resident, who had a moderate cognitive impairment with a BIMS score of 12, was transferred to the hospital following a seizure. Upon his return to the facility after three days, he found that his belongings had been packed and he was moved to a different room without his consent. The resident expressed his dissatisfaction and stated that he had not been asked for permission to move and wanted his original room back. The Director of Nurses (DON) confirmed that the resident's previous bed was no longer available as it had been assigned to two new female residents during his absence. The resident's clinical records, including the Bed-Hold and Return Agreement signed by the resident, indicated that he had requested the facility to hold his bed space during his absence. Despite this, the facility did not honor the agreement, leading to the resident's distress and feeling of being disrespected.
Failure to Provide Proper Oxygen Administration
Penalty
Summary
The facility failed to provide oxygen as ordered by the Medical Doctor (MD) for one of three sampled residents. Resident 1, who was diagnosed with chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD), was observed with an oxygen setting of 2.5 liters instead of the ordered 2 liters. Licensed Vocational Nurse (LVN) 1 confirmed the discrepancy during an interview and record review. The facility's policy and procedure for oxygen administration required verification of the physician's order and proper adjustment of the oxygen delivery device, which was not followed in this case. Additionally, the facility failed to provide humidified oxygen for two of three sampled residents on continuous oxygen. Resident 1 and Resident 2, both diagnosed with COPD and chronic respiratory failure, were observed without humidifiers for their oxygen. Resident 2, who was on oxygen 24 hours a day, confirmed the absence of humidification. The Director of Nursing (DON) acknowledged that all residents on oxygen should have humidifiers to prevent nasal dryness and potential nosebleeds. The facility's policy and procedure for oxygen administration also required the use of a humidifier bottle with water at an appropriate level, which was not adhered to in these instances.
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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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