San Rafael Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 1601 5th Avenue, San Rafael, California 94901
- CMS Provider Number
- 055331
- Inspections on file
- 37
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at San Rafael Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with severe memory impairment and a history of wandering was able to leave the facility unsupervised, despite being identified as an elopement risk and wearing a wander management monitor. Staff did not hear any alarm from the monitor, and the resident was later found by a friend and taken to the responsible party's home. Required sign-out procedures were not followed, resulting in a lapse in supervision.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents experienced delays in call light response, with staff failing to answer requests for assistance in a timely manner, and one resident had a Foley catheter drainage bag left uncovered, contrary to facility policy. Staff interviews confirmed that all staff were responsible for prompt call light response and for maintaining resident privacy and dignity, but these expectations were not met.
A nurse left a medication intended for a resident with dysphagia, who receives tube feedings, unattended on the overbed table. The resident confirmed that staff sometimes leave medications at the bedside, and the Director of Staff Development acknowledged this was a safety issue, as facility policy prohibits leaving medications unattended due to the risk of access by confused residents.
Surveyors found that two toothbrushes in a shared bathroom were not labeled with resident names, contrary to facility policy, creating the potential for accidental use by the wrong individual. Additionally, a resident's Foley catheter tubing was observed touching a contaminated fall mattress, which staff confirmed was against infection control procedures. These failures were verified through staff interviews and review of facility policies.
The facility did not report an alleged sexual abuse incident between two residents to the required authorities within the mandated two-hour timeframe. Staff interviews revealed inconsistent knowledge of abuse reporting guidelines, and the facility's abuse policy had not been updated to reflect current regulations, contributing to the delay and confusion.
Multiple residents were found without access to their call light systems, with devices placed out of reach in locations such as dressers, drawers, and clipped to curtains. Staff, including LNs, the SSD, and the RD, confirmed the inaccessibility of the call lights and acknowledged that they should have been within easy reach, as required by facility policy.
A resident with chronic pain and a stage IV pressure ulcer, who was on hospice care, did not receive a pain reassessment within one hour after receiving morphine as required by facility policy. Instead, the LPN assessed the resident's pain nearly three hours later, at which time the resident continued to report significant pain. The DON confirmed that the pain reassessment policy was not followed.
Several residents and their families were not informed prior to admission that physical therapy would be provided via telehealth and limited to one or two sessions per week. The facility relied on remote therapists due to staffing shortages, and staff changed therapy recommendations to match what could be provided. Residents expressed disappointment and some declined therapy after learning of the telehealth format, while documentation and interviews confirmed that neither residents nor hospital case managers were made aware of these limitations before admission.
A resident with dementia and anxiety disorder suffered two falls, the second resulting in serious fractures, after the facility failed to implement and document care plan interventions such as PT, frequent room checks, and objective monitoring of behaviors and medication side effects. Nursing and therapy interventions were not consistently ordered or recorded, and staff could not provide evidence of required monitoring in the medical record.
A facility failed to notify the LTC Ombudsman of a resident's transfer to an emergency department, as required by regulations. The Social Services Director and Director of Nursing acknowledged the oversight, citing the newness of the regulation. The Medical Record Director confirmed the lack of documentation. The All Facilities Letter mandates such notifications to protect resident rights.
A resident was prescribed an anti-anxiety medication without first attempting non-pharmacologic interventions or monitoring for side effects and adverse drug reactions. Facility staff confirmed the importance of these steps, but the resident's records showed no evidence of such actions.
A resident did not receive scheduled medications on time, with significant delays noted in administration. Additionally, a CNA was observed lying in a resident's bed and using a personal cellphone, actions that were against the facility's policies. Both incidents were confirmed by facility administrators.
A resident with diabetes received insulin on multiple occasions despite having blood sugar levels below the prescribed threshold of 120. An LVN administered insulin when the resident's blood sugar was 74, leading to symptoms of low blood sugar. The DON confirmed a pattern of inappropriate insulin administration, and the facility's policy required adherence to physician orders and proper assessment of blood sugar levels.
The facility failed to properly label and store medications, supplements, and supplies, leading to several deficiencies. A resident had a prescription medication at their bedside without an order, and an LVN left medication bubble packs unattended. Used topical medications lacked caps, and wound dressings were found open and unlabeled. Expired syringes were in the emergency cart, and the medication refrigerator was not at the correct temperature. Expired medications were found in a cart, and unsecured medication was at a resident's bedside, posing potential risks.
The facility failed to store food in safe and sanitary conditions, with unlabeled and uncovered cucumbers in the kitchen refrigerator and expired items in the emergency food storage area. The Dietary Manager confirmed the lack of labeling and dating, which is required by facility policy and the FDA Food Code to prevent food-borne illnesses.
A resident with COPD was unable to reach her call light, which was tied to the bed rail and hanging off the bed. The DON confirmed the call light should be within reach, and an OT noted it should be placed on her lap due to limited arm motion. The facility's policy requires residents to have a means of contacting staff, which was not followed.
A resident was moved to a different room without prior written notification, as required by the facility's policy. The resident was instructed to move by staff without any advance notice, and the facility's Administrator confirmed the oversight. The resident's Electronic Health Record lacked documentation of the room change notification.
A resident reported that the shower water never stayed warm. An observation with the Maintenance Director showed the water temperature was 90°F, below the required 110°F as per facility policy. This failure resulted in the resident not receiving a comfortable shower.
The facility failed to notify the ombudsman of the transfer of a resident to the hospital and the discharge of another resident to home, as required by their policy. The Director of Medical Record and Assistant Administrator confirmed the lack of notification, and the facility's ombudsman was not informed of these events.
A resident admitted with PTSD, anxiety disorder, and major depressive disorder did not have their Level I PASRR reassessed by the facility, leading to potential gaps in mental health services. Additionally, the resident's MDS inaccurately indicated an active diagnosis of viral hepatitis, despite no treatment orders, resulting in incorrect data transmission to CMS.
The facility failed to develop a fall care plan for a resident with a history of multiple falls and a physical therapy care plan for another resident requiring rehabilitation services. Despite the facility's policies, these care plans were not initiated, leaving the residents without necessary interventions.
A resident with spinal stenosis and failure to thrive was not provided timely feeding assistance, as observed on two occasions with untouched lunch trays. The resident was nonverbal and unable to feed himself, requiring assistance that was delayed due to staff workload. The facility's policy on accommodating residents' needs was not followed, risking potential weight loss.
A resident admitted for rehabilitation services did not receive ordered physical therapy from mid-January to mid-March due to staff unavailability. This oversight, confirmed by the Director of Rehabilitation and facility administrators, left the resident frustrated with her recovery progress.
A facility failed to label an enteral feeding bottle, pump bag, and syringe for a resident, risking cross-contamination. The resident, admitted with a gastrostomy malfunction, had specific physician orders for enteral feeding. The facility's policy required labeling with the date and time, which was not followed, leading to a deficiency.
An LVN failed to properly prime a Lantus insulin pen before administering it to a resident with diabetes mellitus type 2. The LVN incorrectly primed the pen before attaching the needle, contrary to the guidelines, which require priming with the needle attached to ensure an accurate dose. This oversight was confirmed by the DON and had the potential to compromise the medication dose.
A LTC facility was found to have a medication error rate of 8.33%, exceeding the acceptable threshold. Errors included administering Losartan without checking blood pressure, giving Insulin Glargine without a current blood sugar reading, and failing to administer Metoprolol due to pharmacy unavailability without notifying the physician. These actions were against the facility's policies and had potential health implications for the residents.
A resident admitted for rehabilitation services did not receive prescribed physical therapy from January to March due to staff unavailability. The resident, who had a shattered kneecap and broken femur, expressed frustration over the delay in recovery. Facility staff, including the DON and physician, were unaware of the missed treatments.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents. A PTA assisted a resident with a chronic ulcer without wearing a gown, contrary to EBP requirements. An RNA repositioned another resident with a chronic wound and Foley catheter without a gown, unaware of the EBP status. Additionally, a resident with an open wound was not placed on EBP, and no sign was posted to inform caregivers of necessary precautions.
A resident with cognitive and physical impairments was found with black insects in her bed, despite previous reports to environmental services. The CNA and DON confirmed the presence of ants, and a housekeeper also observed the insects. The facility's housekeeping policy mandates a clean and sanitary environment to ensure resident safety.
A resident with multiple mental health diagnoses was moved to a different room without prior written notice to their responsible party (RP). The facility's policy requires advance notice and participation in such decisions, but the RP was informed only after the move. The Social Services Director cited safety concerns as the reason for the move.
A resident with Alzheimer's Disease and severe cognitive impairment eloped from the facility unsupervised due to the lack of a person-centered care plan addressing their wandering and elopement risk. Despite using a Wander Management Monitor, no care plan was documented, and staff interviews confirmed previous elopement attempts. The CNA at the front desk did not notice the resident leaving or hear the door alarm.
A resident with Alzheimer's Disease and severe cognitive impairment eloped from the facility without staff knowledge. Despite having a Wander Management Monitor, the resident left through the front door and was returned by a neighbor after 15 minutes. The facility lacked a documented care plan for the resident's elopement risk, and staff failed to notice the departure or hear the door alarm, indicating inadequate supervision.
A resident with end-stage renal disease experienced deficiencies in dialysis care management, including the lack of a physician's order for dialysis, failure to include the dialysis schedule in the care plan, and issues with transportation leading to missed or shortened sessions. Facility staff did not document missed appointments or notify the physician, and there was confusion about the resident's schedule and transportation arrangements.
The facility failed to validate the competencies of registry nurses, risking resident care by potentially unqualified staff. The DON could not provide a registry nurse's competency evaluation, as records were with the staffing agency. The Administrator was unaware of the agency's evaluation process, and the facility's policy did not cover registry staff.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A resident with a diagnosis of toxic encephalopathy and severe memory impairment was admitted to the facility and identified as being at risk for elopement due to mental confusion and memory loss. The resident's care plan included the use of a wander management monitor, which was documented as being in place and functioning. Physician orders specified that the resident could only leave the facility with supervision. Despite these measures, the resident was able to leave the facility unaccompanied, walk several busy streets, and was eventually found by a friend who transported him to his responsible party's home. Staff interviews revealed that the resident was last seen in the facility's lobby and was discovered missing when a nurse checked on him for dinner. Neither the nurse nor the CNA assigned to the resident heard the wander management monitor alarm. The resident was still wearing the monitor when he arrived at his responsible party's home, and it was later removed with scissors. Facility policy required residents or their responsible persons to notify a licensed nurse and sign out when leaving on a pass, but this procedure was not followed. The failure to provide adequate supervision and ensure the effectiveness of the wander management system resulted in the resident's unsupervised departure from the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Timely Call Light Response and Privacy for Residents
Penalty
Summary
Two residents experienced failures related to respect, dignity, and the right to personal property. One resident, who was dependent on staff for toileting and personal hygiene due to chronic pain syndrome and functional quadriplegia, had a call light activated for assistance. Multiple staff members were observed passing by the call light without responding, and the resident reported previous instances of waiting for hours for assistance, sometimes resorting to yelling without receiving help. Staff interviews confirmed that answering call lights was the responsibility of all staff and should occur within a few minutes, but this expectation was not met. Another resident, admitted with dysphagia and requiring assistance with personal care, also reported waiting between 30 minutes to an hour for staff to answer her call light. She described the experience as frustrating and disrespectful. Staff and facility leadership confirmed that the facility's policy required call lights to be answered promptly, typically within 2 to 3 minutes, and that delays beyond 10 minutes were unacceptable. Additionally, the first resident was observed with a Foley catheter drainage bag that did not have a privacy cover, contrary to facility policy. The resident stated that staff never placed a cover on the drainage bag and was unaware if the facility had any. Staff interviews confirmed that covering the drainage bag was required to protect privacy and dignity, and failure to do so could cause residents to feel humiliated or undignified. Facility policies reviewed also emphasized the importance of prompt call light response and maintaining resident privacy and dignity.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a nurse left a whitish watery medication, intended for a resident with dysphagia who receives nutrition and medication via feeding tube, unattended on the resident's overbed table. The resident confirmed that the medication was left by the nurse and stated that staff sometimes leave medications at her bedside or overbed table. Observations confirmed the medication and a syringe were left unattended, and the nurse acknowledged that this was against facility policy due to safety concerns, especially given the presence of confused residents who wander and could access the medication. The Director of Staff Development verified that the medication was left unattended and confirmed it was a safety issue. Facility policy requires that medications, once removed from their packaging, should be administered safely or disposed of according to the medication destruction policy, and that bedside medication storage is only permitted when it does not present a risk to confused residents. The failure to follow these procedures resulted in the medication being left in a location accessible to unintended persons.
Infection Control Deficiencies: Unlabeled Toothbrushes and Improper Catheter Care
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices affecting three out of five sampled residents. During observations, two toothbrushes were found in a shared bathroom without labels identifying which resident each belonged to. Unlicensed staff confirmed that the facility's policy requires toothbrushes to be labeled with resident names, especially when stored in shared spaces, to prevent confusion and accidental use by the wrong resident. The Director of Staff Development also verified that labeling is necessary for infection control and to ensure each resident uses their own toothbrush. Additionally, a resident with a Foley catheter was observed with the catheter tubing touching a fall mattress, which is considered a contaminated surface. Licensed nursing staff and unlicensed staff both acknowledged that facility policy prohibits catheter tubing from touching the floor or fall mattress due to the risk of contamination. The Director of Staff Development confirmed that such contact is unsanitary and could result in infection. A review of the facility's policies and procedures corroborated the requirements for labeling personal hygiene items and ensuring catheter tubing does not come into contact with contaminated surfaces. These lapses in following established infection control protocols were directly observed and verified by staff interviews, indicating a failure to maintain a safe and sanitary environment as required by federal regulations.
Plan Of Correction
F 880 F 880 F 880 F 880 SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure residents are treated with respect and dignity, including the right to retain and use personal possessions, and to ensure call lights are answered promptly and catheter drainage bags are properly covered to maintain resident privacy and dignity. Corrective Action for Affected Residents: On 6/3/25, Resident 1's foley catheter drainage bag was immediately provided with a privacy cover. On 6/3/25, the Director of Nursing (DON) and DSD conducted one-on-one counseling with staff members who failed to respond to Resident 1's call light. The DON met with both Resident 1 and Resident 2 to address their concerns regarding call light response times and implemented immediate monitoring of call light response times for their rooms. Identifying other Residents having the Potential to be Affected: On 6/4/25, the DON and DSD conducted a facility-wide audit of all residents with foley catheters to ensure proper privacy covers were in place. A facility-wide assessment of call light response times was conducted for all residents from 6/4/25 to 6/6/25 to identify any additional concerns with call light response times. Measures put into place or Systemic Changes: The DON or designee will conduct in-service education for staff by 7/1/2025 on: • Call light response protocols and expectations for maximum response (promptly) • Proper use and importance of foley catheter privacy covers • Resident dignity and respect requirements • Staff accountability for responding to call lights regardless of assignment New processes implemented include: • Call light monitoring audit to track response times Plan to Monitor Performance: The DSD will conduct audits of call light response times and catheter privacy cover compliance weekly for 8 weeks, and monthly thereafter. Audits will include: • Random observations of call light response times • Review of call light monitoring audit data • Inspection of all catheter drainage bags for proper privacy covers & positioning • Interviews with residents regarding satisfaction with call light response times via audit tool The DON will analyze audit results and report findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly. The QAPI committee will review the effectiveness of interventions and make additional recommendations as needed until substantial compliance is achieved and maintained.
Failure to Timely Report Alleged Sexual Abuse and Update Abuse Reporting Policy
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving two residents within the required two-hour timeframe to the local ombudsman, the California Department of Public Health, and local law enforcement. The incident occurred when one resident inappropriately touched another resident, and the event was reported to the facility's dietary supervisor. However, the official report to the state was not sent until over three hours after the incident, exceeding the mandated reporting window. Both the Social Services Director and the Director of Staff Development confirmed that the report did not meet the two-hour guideline and acknowledged the importance of timely reporting for resident safety. Interviews with facility staff revealed a lack of consistent knowledge regarding abuse reporting guidelines. Licensed nurses and unlicensed staff provided varying answers about the appropriate authorities to notify and the required timeframe for reporting abuse allegations. Some staff believed that all abuse allegations should be reported within 24 hours, while others were unclear about when to involve law enforcement, indicating confusion about the current regulatory requirements. A review of the facility's abuse policy and procedure showed that it had not been updated to reflect the most recent reporting guidelines as outlined in the All Facilities Letter 21-26. The policy, last revised in 2014, did not fully align with current federal and state requirements for reporting suspected abuse, neglect, or exploitation, particularly regarding the two-hour reporting mandate for incidents involving abuse or serious bodily injury. This outdated policy contributed to the staff's inconsistent understanding and the facility's failure to report the incident in a timely manner.
Call Light System Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to four out of five sampled residents, as required by facility policy. During observations and interviews, it was found that one resident's call light was stored in a box on a dresser, and the resident was unaware of its location. Another resident was unable to reach her call light, which was clipped to a curtain out of her reach. A third resident did not know where her call light was, and it was confirmed to be attached to a curtain, making it inaccessible. The fourth resident's call light was found behind her, in a drawer on a dresser, and not within her reach while she was seated in a reclined chair. Staff members, including licensed nurses, the Social Services Director, and the Registered Dietician, confirmed during interviews that the call lights were not within reach of the residents and acknowledged that they should have been. The Director of Nursing also stated that it was her expectation for call lights to be easily accessible to residents and recognized that having them out of reach could pose a safety issue. A review of the facility's policy confirmed that call cords are to be placed within the resident's reach in their rooms.
Failure to Timely Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, a stage IV pressure ulcer, and on hospice care did not receive timely reassessment of pain following administration of pain medication. The resident's care plan required pain to be managed with both scheduled and PRN medications, and the facility's policy specified that pain intensity should be reassessed one hour after administration of pain medication. However, after the resident was given morphine for pain, the licensed nurse did not perform the required follow-up pain assessment within the one-hour timeframe. Instead, the nurse assessed the resident's pain nearly three hours after medication administration, at which time the resident continued to report pain, describing a sensation of having a ball inside her abdomen and rating her pain as a five while visibly grimacing and holding her abdomen. The nurse documented the follow-up assessment as "effective" despite the resident's ongoing pain. The DON confirmed that the facility's policy was not followed, as the reassessment should have occurred one hour after medication administration.
Failure to Inform Residents of Telehealth Physical Therapy and Limited Session Frequency
Penalty
Summary
The facility failed to fully inform residents about the nature and frequency of their physical therapy services prior to admission, specifically that therapy would be provided via telehealth and limited to one or two sessions per week. Multiple residents and their family members reported that they were not told about the telehealth format or the reduced frequency of therapy sessions before admission. Some residents expected in-person therapy and a higher frequency of sessions, as was communicated to them by hospital staff or based on their previous experiences in other facilities. The marketing director and staff involved in admissions did not consistently disclose these details, and there was no written consent for telehealth therapy; only verbal consent was obtained at the start of sessions. Observations and interviews revealed that the facility had been unable to hire a full-time physical therapist, resulting in reliance on telehealth services provided by therapists located remotely. The rehabilitation director confirmed that therapy was limited to one or two sessions per week due to staffing constraints, and that recommendations for more frequent therapy were changed to match what the facility could provide. Residents expressed disappointment and frustration with the telehealth format and the limited frequency, with some stating that their progress was slower than expected or that they were not making improvements. Two residents chose not to participate in physical therapy after learning it would be conducted via telehealth. Documentation reviews showed that initial therapy recommendations for higher frequency were altered by facility staff to reflect the reduced availability. Staff interviews confirmed that prospective residents and their families were not informed about the telehealth delivery or session limitations prior to admission, and that hospital case managers were also unaware. The facility's own policy emphasized residents' rights to be informed and participate in care planning, but this was not upheld in practice for the sampled residents.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
A resident with dementia and anxiety disorder, who was independently mobile prior to admission, experienced a fall resulting in a head laceration and hand skin tear. Following this incident, the care plan was updated to include interventions such as a PT consult, frequent room checks, and staff education on safety. However, the facility failed to implement and monitor these interventions effectively. Specifically, there was no physician's order for PT, and the resident did not receive PT services after the evaluation and plan of treatment were completed. Additionally, there was no documentation in the medical record to confirm that frequent room checks or monitoring interventions were conducted as required by the care plan. Nursing staff reported that rounding and monitoring of fall risk residents were performed, but these actions were not consistently documented in the resident's medical record or the electronic medical record system. The DON and DSD acknowledged that documentation of fall interventions should have been present but could not locate any records to support that monitoring was performed. Communication about monitoring was maintained on paper forms or communication sheets, which were not part of the official medical record, further contributing to the lack of evidence that interventions were carried out. The facility also failed to follow the consultant pharmacist's recommendation to objectively monitor and quantify behaviors and side effects related to the resident's psychoactive medication, lorazepam. The MAR only indicated whether a behavior was observed, without specifying which behaviors or side effects were being monitored, and there was no objective data collected. This lack of monitoring and documentation contributed to the resident experiencing a second fall, resulting in a left intertrochanteric hip fracture and a T3 vertebral fracture, which significantly reduced the resident's mobility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care Ombudsman for one of the sampled residents. This deficiency was identified during interviews and record reviews, where it was found that there was no evidence of the notice being sent when the resident was transferred to an emergency department. The Social Services Director acknowledged that a notice of transfer form should have been completed and sent to the Ombudsman to protect the resident's rights. The Director of Nursing confirmed the oversight, attributing it to the regulation being relatively new. The Medical Record Director also verified the absence of documentation indicating that the Ombudsman was notified. The All Facilities Letter AFL-17-27, effective from January 1, 2018, mandates that LTC facilities notify the local LTC Ombudsman at the same time notice is provided to the resident or their representatives when a transfer or discharge occurs, including emergency transfers to a general acute care hospital.
Failure to Implement Non-Pharmacologic Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident was prescribed an anti-anxiety medication without implementing non-pharmacologic interventions to address the resident's behavior. Additionally, there was no monitoring of the resident's behavior, response to the medication, or monitoring for side effects and adverse drug reactions. This lack of monitoring and absence of non-pharmacologic interventions put the resident at risk of side effects and adverse drug reactions related to the psychotropic medication use. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, confirmed that non-pharmacologic interventions should be attempted first before administering psychotropic medications. They also emphasized the importance of monitoring the resident's behavior and any side effects or adverse drug reactions when on such medication. However, the resident's electronic medical record did not indicate any such monitoring or interventions were in place, which was verified by the Director of Nursing.
Medication Administration and Staff Conduct Deficiencies
Penalty
Summary
The facility failed to ensure that Resident 54 received scheduled medications in a timely manner. During an observation and interview, it was noted that Resident 54 received her medications, including ibuprofen, docusate, multivitamin, and ascorbic acid, significantly later than scheduled. The medications were supposed to be administered at 8 a.m. and 9 a.m., but were not given until 11:42 a.m. This delay was confirmed during a review of the Medication Admin Audit Report and acknowledged by the Administrator, who stated that medications should be administered within an hour of the scheduled time. The facility's policy on medication administration supports this standard. Additionally, the facility failed to maintain professional standards of conduct when CNA 1 was observed lying in Resident 37's bed and using a personal cellphone. This incident occurred while Resident 37 was in the dining room for lunch. The Director of Nursing and the Administrator both confirmed that staff should not use personal cellphones in patient care areas and should not be in residents' beds. The facility's policy on employee conduct prohibits malingering on the job and the use of personal communication devices in resident care areas.
Insulin Administered Despite Low Blood Sugar
Penalty
Summary
The facility failed to ensure that insulin was not administered to a resident when their blood sugar was below the target range of 120. This deficiency was observed in one of the sampled residents, who received insulin on 10 out of 19 days in March 2025 despite having blood sugar levels below 120. On March 19, 2025, a Licensed Vocational Nurse (LVN) administered 15 units of Insulin Glargine to the resident when their blood sugar was 74, contrary to the physician's order to hold insulin if blood sugar was less than 120. The resident was later observed to be sweating and lethargic, symptoms indicative of low blood sugar. The Director of Nursing (DON) confirmed that there was a pattern of insulin administration when the resident's blood sugar was below 120 on multiple days in March. The facility's policy and procedure for medication administration required that medications be administered as prescribed, with necessary tests performed and results recorded. The pharmacist stated that the standard practice was for nurses to assess blood sugar levels before administering insulin and to follow the physician's orders. The failure to adhere to these protocols resulted in the administration of insulin when it was not required, potentially leading to low blood sugar symptoms in the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, supplements, and supplies, leading to several deficiencies. A prescription nystatin powder was found on a resident's bedside table without an order to keep it there, and the resident had obtained it from an outside pharmacy due to insurance issues. Additionally, two medication bubble packs were left unattended on top of a medication cart by an LVN, which was confirmed by the Director of Nursing (DON) as a breach of protocol. Further observations revealed that two used topical medications in the treatment cart lacked caps, and a collagen matrix dressing and Xeroform gauze dressing were found open and unlabeled. The Infection Preventionist confirmed these items should have been discarded or properly labeled. Moreover, five expired syringes with needles were discovered in the emergency cart, and the medication refrigerator was not maintained at the correct temperature, with no interventions documented for the out-of-range temperatures. Expired medications were also found in one of the medication carts, and unsecured medication was observed at the bedside of a resident. The DON confirmed that medications should not be left at the bedside, as it poses a risk of another resident taking them. These deficiencies indicate a failure to adhere to the facility's policies and procedures regarding medication storage and safety, potentially leading to adverse clinical outcomes.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored in safe and sanitary conditions, as observed in the kitchen refrigerator and the Dry Food Storage Area. During an inspection, it was found that seven cucumbers were left uncovered and undated in the kitchen refrigerator. Additionally, individual-packed Italian dressings and yellow mustards in the Dry Food Storage Area were not labeled with received or expiration dates. The Dietary Manager (DM) confirmed that the expectation was for all food to be labeled and dated to prevent cross-contamination and food-borne illnesses. The facility's policy and procedure, as well as the 2022 FDA Food Code, require that all food items be labeled and dated to ensure safety. In the emergency food storage area, six gelatin boxes and six cans of three-bean salad were found to be expired and not labeled with received or expiration dates. The DM acknowledged that these items were expired and not safe for consumption, which could lead to food-borne illnesses. The DM also stated that she was solely responsible for restocking and checking the emergency food storage area. The facility's policy and procedure mandates that all canned and dry storage products be labeled and dated, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light for one of the residents was within her reach, which had the potential for her needs not being met. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was observed lying in bed with her call light tied to the left bed rail and hanging off the bed, making it unreachable for her. During an interview, the resident confirmed that she could not reach the call light and used it to call for assistance. The Director of Nursing (DON) also confirmed the call light's location and acknowledged that it should be within the resident's reach. An Occupational Therapist (OT) further stated that due to the resident's limited range of motion with her arms, the call light should be placed on her lap in front of her. The facility's policy and procedure on the communication call system indicated that residents should have a means of contacting staff for assistance, which was not adhered to in this case.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to provide a written notification to a resident regarding a room or roommate change, as required by their policy. The resident reported waking up to multiple male staff members instructing her to move to a different room without prior notification. The facility's Administrator confirmed that the resident's room was changed in June 2023, and acknowledged that the resident should have been notified in advance. A review of the resident's Electronic Health Record did not show any bed change notification, and the facility's policy mandates that residents receive timely advance written notice of room changes, including the reasons for such changes.
Inadequate Shower Water Temperature for Resident
Penalty
Summary
The facility failed to ensure a comfortable shower experience for a resident due to inadequate water temperature. During an interview, the resident reported that the shower water never stayed warm. An observation and interview with the Maintenance Director in the Spa Shower Room revealed that the shower's hot water temperature was only 90 degrees Fahrenheit after three minutes, whereas it should have been 110 degrees Fahrenheit according to the facility's policy. The facility's policy, dated January 2, 2012, indicated that water temperatures should be maintained at levels suitable to meet residents' needs.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the ombudsman of the transfer and discharge of two residents, which is a requirement according to their policy. Resident 58 was transferred to the hospital due to a fever and possible sepsis, but there was no documented evidence that the ombudsman was notified of this transfer. The Director of Medical Record confirmed the lack of notification, and the Director of Nursing and Director of Social Services were unaware of the requirement to notify the ombudsman for hospital transfers. The facility's ombudsman also confirmed that she was not notified of Resident 58's transfer. Similarly, Resident 59 was discharged home, but again, there was no documented evidence that the ombudsman was notified. The Assistant Administrator confirmed this oversight, and the facility's ombudsman stated she was not informed of Resident 59's discharge. The facility's policy and procedure require notification of the ombudsman for transfers or discharges initiated by the facility, but this was not followed in these cases.
Inaccurate Assessment and Data Submission for Resident
Penalty
Summary
The facility failed to reassess and submit accurate data for a resident upon admission, which led to deficiencies in the resident's care plan. The resident, who was admitted with diagnoses of PTSD, anxiety disorder, and major depressive disorder, did not have their Level I PASRR reassessed by the facility. The initial PASRR assessment, completed by the discharging hospital, indicated a negative result, which did not reflect the resident's active mental health diagnoses. The facility's policy required a PASRR reassessment to ensure accurate screening for mental illness and intellectual disability, which was not conducted, potentially affecting the resident's access to necessary mental health services. Additionally, the facility transmitted inaccurate data to CMS due to errors in the resident's MDS. The MDS indicated an active diagnosis of viral hepatitis, despite the resident having no treatment orders for this condition. The resident was discharged from the hospital with a diagnosis of Chronic Hepatitis B, but the MDS should not have been coded for an active infection. The facility's failure to accurately code the MDS resulted in the transmission of incorrect data, as the CMS LTCF RAI 3.0 User's Manual specifies that only diseases with a direct relationship to the resident's current status should be coded as active.
Failure to Develop Care Plans for Fall Risk and Physical Therapy
Penalty
Summary
The facility failed to develop a fall care plan for a resident who was admitted with diagnoses of dementia, abnormalities of gait and mobility, and difficulty in walking. Despite having a history of multiple falls within the facility, there was no fall care plan in place to address the resident's high risk for falls. The Director of Nursing confirmed the absence of a fall care plan, which was contrary to the facility's Fall Management Program policy that requires the interdisciplinary team to initiate, review, and update the resident's fall risk status and care plan at specified intervals. Additionally, the facility did not develop a physical therapy care plan for another resident who was admitted with obesity and difficulty in walking, and who required rehabilitation services following a shattered kneecap and broken left femur. Despite physician's orders for physical therapy three times a week, there was no documented evidence of a physical therapy care plan. The facility's policy on Comprehensive Person-Centered Care Planning mandates the development of a comprehensive care plan within seven days from the completion of the comprehensive MDS assessment, which was not adhered to in this case.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely assistance with feeding for a resident who was unable to feed himself, leading to a potential risk of weight loss. The resident, who was admitted with diagnoses including spinal stenosis and failure to thrive, was observed on two separate occasions with an untouched lunch tray on his bedside table. The resident was nonverbal and unable to move his arms or hands to feed himself, indicating a clear need for assistance. During an interview, the Director of Nursing confirmed that the resident required feeding assistance and should not have been left waiting. A Certified Nursing Assistant also acknowledged that the resident had to wait for feeding assistance due to having multiple residents to care for. The facility's policy on accommodating residents' needs was not adhered to, as the resident's individual needs for feeding assistance were not met in a timely manner, despite a registered dietitian's note specifying the need for one-on-one assistance with meals and snacks as part of a weight loss intervention plan.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide necessary physical therapy services to a resident, identified as Resident 9, who was admitted with diagnoses of obesity and difficulty in walking, following a shattered kneecap and a broken left femur. Despite physician's orders for physical therapy three times a week for four weeks, the resident did not receive these services from January 14, 2025, to March 16, 2025, due to the unavailability of physical therapy staff. This lack of service led to Resident 9 feeling frustrated about her recovery progress, as she was in the facility primarily for rehabilitation services. Interviews with the Director of Rehabilitation, Director of Nursing, and the attending physician revealed that none were aware of the lapse in physical therapy services for Resident 9. The facility administrators also confirmed the oversight and acknowledged that the physician should have been notified about the missed treatments. The deficiency was identified through a review of the resident's records and interviews, which confirmed the absence of documented attempts to provide the ordered physical therapy during the specified period.
Failure to Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to properly label an enteral feeding bottle, pump bag, and syringe for a resident, which could lead to cross-contamination. During an observation, it was noted that a bottle of Glucerna 1.5, an enteral feeding pump bag containing a clear liquid, and a syringe were hanging on a pole in the resident's room without labels or dates. The Director of Staff Development confirmed that these items should have been labeled with the resident's name, room number, and the expiration date of the enteral feeding. The resident involved had been admitted with a diagnosis of gastrostomy malfunction. The physician's orders indicated specific instructions for changing the enteral tubing and syringe daily and administering Glucerna 1.5 at a specified rate and duration. The facility's policy required labeling of the bag and tubing with the date and time hung, with a hang time of no more than 24 hours. The failure to adhere to these labeling protocols was identified as a deficiency during the survey.
Improper Priming of Insulin Pen by LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly primed a Lantus insulin pen before administering it to a resident diagnosed with diabetes mellitus type 2. During a medication administration observation, the LVN removed the cap of the Lantus insulin pen, turned the dial, and pressed the injection button before attaching and screwing the needle onto the pen. The LVN incorrectly stated that the pen needed to be primed before attaching the needle, which contradicts the proper procedure outlined in the Lantus SoloStar pen guidelines. The Director of Nursing confirmed that the correct procedure involves priming the insulin pen with the needle already attached. The guidelines specify that after attaching the needle, a safety test should be performed by dialing a test dose, holding the pen with the needle pointing up, and lightly tapping the insulin reservoir to allow air bubbles to rise to the top. This ensures an accurate dose is administered. The failure to follow these steps had the potential to compromise the medication dose given to the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 8.33%. Three specific medication errors were identified during the survey. The first error involved the administration of Losartan Potassium to a resident without checking their blood pressure beforehand, despite the medication label indicating it should be held if the systolic blood pressure (SBP) was less than 110. The Licensed Vocational Nurse (LVN) confirmed that the blood pressure was not checked prior to administration, which was against the facility's policy and procedure. The second error involved the administration of Insulin Glargine to the same resident without obtaining a current blood sugar reading. The LVN administered the insulin based on a previous shift's blood sugar result of 74, which was below the threshold of 120 indicated in the medication order. The LVN acknowledged the mistake and confirmed that insulin should not have been administered under these conditions. This was also contrary to the facility's policy, which required blood sugar monitoring before insulin administration. The third error occurred when Metoprolol Succinate ER was not administered to the resident as per the physician's order because it was unavailable from the pharmacy. The LVN did not notify the physician about the unavailability of the medication. This oversight was a violation of the facility's policy, which mandates that medications be administered as prescribed. These errors had the potential to result in adverse health outcomes for the residents involved.
Failure to Provide Prescribed Physical Therapy
Penalty
Summary
The facility failed to provide physical therapy treatment as ordered by a physician for a resident who was admitted with a shattered kneecap and a broken left femur. The resident was in the facility primarily for rehabilitation services but had not received physical therapy from January 14 to March 16, despite having physician's orders for therapy three times a week. The Director of Rehabilitation confirmed the lack of documented evidence of attempts to provide the therapy during this period, citing the unavailability of physical therapy staff as the reason. Interviews with the resident, the Director of Nursing, the physician, and the facility administrators revealed that none were aware of the missed physical therapy treatments. The resident expressed frustration over the lack of therapy, which she believed was delaying her recovery and her ability to walk enough to return home. The physician and administrators acknowledged that the resident was in the facility for rehabilitation and should have been receiving the prescribed therapy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control practices for three residents who were on Enhanced Barrier Precautions (EBP). For Resident 7, a Physical Therapist Assistant (PTA) was observed assisting the resident without wearing a gown, despite the resident being on EBP due to a chronic ulcer and a history of MSSA. The PTA's clothes came into contact with the resident's bedsheets, and the PTA stated that she was informed by a nurse that only gloves were necessary. The facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines require the use of gowns and gloves during such interactions. Similarly, for Resident 55, a Restorative Nursing Assistant (RNA) was observed repositioning and changing the resident's blanket without wearing a gown, even though the resident was on EBP due to a chronic wound and a Foley catheter. The RNA was unaware of the EBP status and acknowledged the need for a gown during high-contact care. The Infection Preventionist confirmed that the RNA should have worn a gown, as per the facility's infection control policy. Additionally, Resident 1, who had an open wound and required daily dressing changes, was not placed on EBP. There was no EBP sign posted outside the resident's room, which was verified by both a Registered Nurse and the Infection Preventionist. The facility's policy mandates posting EBP signs for residents with open wounds to inform caregivers of the necessary precautions. This oversight was contrary to the guidelines outlined in the facility's infection prevention and control manual and the All Facilities Letter from the California Department of Public Health.
Insect Infestation in Resident's Bed
Penalty
Summary
The facility failed to maintain a sanitary environment for one of the sampled residents, identified as Resident 3, who was observed with black insects crawling in her bed. Resident 3, who was admitted with diagnoses including cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness, was found lying in bed with tiny black insects scattered around the bed linens and on her legs. A Certified Nursing Assistant (CNA) confirmed that Resident 3 was dependent on all care and had difficulty communicating her needs. The CNA mentioned that this issue had been reported to environmental services a couple of months ago. The Director of Nursing (DON) also observed the insects and identified them as ants. A housekeeper confirmed seeing the insects in Resident 3's room on the same day. The facility's housekeeping policy, dated 1/1/12, requires the facility to be clean and sanitary at all times to promote the health and safety of residents.
Failure to Notify Resident's Responsible Party of Room Change
Penalty
Summary
The facility failed to provide a written notice to the responsible party (RP) of a resident before moving the resident to a different room. The resident, who was admitted to the facility with diagnoses including autistic disorder, anxiety disorder, and schizoaffective disorder bipolar type, was moved without prior notification to the RP. The room change notification indicated that the RP was notified after the move had already occurred, and the care plan was not updated at the time of the move. The facility's policy requires that residents and their representatives receive timely advance written notice of room changes, including the reasons for the change. Interviews revealed that the resident's RP was not informed of the room change until after it had been completed. The Social Services Director stated that the move was necessary for the safety of the resident and his roommate, as the resident was interfering with the roommate's belongings and personal space. However, the RP confirmed that she was not consulted or given the opportunity to participate in the decision-making process prior to the move, which is a violation of the resident's rights as outlined in the facility's policy.
Failure to Implement Care Plan for Resident's Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with Alzheimer's Disease, who was at high risk of elopement. Despite the resident's severe cognitive impairment and use of a manual wheelchair, the facility did not initiate a care plan addressing the resident's wandering and elopement risk. This oversight was evident when the resident eloped from the facility unsupervised, as documented in the facility's records and confirmed by staff interviews. The resident's records indicated the use of a Wander Management Monitor, but there was no documented care plan for elopement risk prior to the incident. Interviews with the Director of Nursing and the Administrator revealed that the resident had attempted to leave the facility before, yet no care plan was in place. The Certified Nursing Assistant assigned to the front desk did not notice the resident leaving and did not hear the door alarm, further highlighting the lack of adequate supervision and care planning for the resident's safety needs.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident with Alzheimer's Disease, resulting in the resident eloping from the facility without staff knowledge. The resident, who had a severe cognitive impairment and used a manual wheelchair for mobility, was admitted to the facility in January 2024. Despite having a Wander Management Monitor (WMM) ordered to be placed on the resident's wrist in October 2024, the resident managed to leave the facility unsupervised on February 10, 2025. The resident was returned to the facility by a neighbor after being outside for approximately 15 minutes. Interviews and record reviews revealed that the facility did not have a documented care plan addressing the resident's risk of elopement, even though the resident had attempted to leave the facility in the past. The Director of Nursing confirmed the elopement incident, and the Administrator acknowledged that the front door was the only accessible exit for the resident. The Certified Nursing Assistant assigned to the front desk did not notice the resident leaving and did not hear the door alarm, indicating a lapse in supervision and monitoring. The facility's policy on wandering and elopement was not effectively implemented, as staff failed to prevent the resident's departure or follow the resident to ensure safety until assistance arrived.
Deficiencies in Dialysis Care Management
Penalty
Summary
The facility failed to manage the dialysis care for a resident with end-stage renal disease, as evidenced by several deficiencies in their care processes. The staff did not obtain a physician's order for the resident's dialysis, which is crucial for ensuring that the resident's dialysis schedule is accurately reflected in their care plan and medication administration record. This oversight meant that the resident's dialysis schedule was not included in their care plan, leading to confusion about the resident's treatment schedule. Additionally, the facility failed to ensure timely transportation for the resident to their dialysis appointments. The resident was either transported late or not at all, resulting in missed or shortened dialysis sessions. The facility did not document these missed appointments or notify the resident's physician, which is essential for maintaining continuity of care and ensuring that the resident's health needs are met. The lack of documentation and communication could potentially leave the resident's healthcare providers unaware of the frequency and reasons for missed dialysis sessions. Interviews with facility staff revealed a lack of clarity and responsibility regarding the resident's dialysis schedule and transportation arrangements. The Social Services Director and MDS Nurse were unsure of the resident's dialysis schedule and did not ensure it was accurately documented in the electronic medical record. Furthermore, the facility's policy on dialysis management was not followed, as documentation concerning dialysis services was not maintained in the resident's medical record, and there was no system for scanning assessments into the electronic record.
Failure to Validate Competencies of Registry Nurses
Penalty
Summary
The facility failed to establish a system for validating the competencies of registry nurses, which could lead to residents being cared for by nurses lacking necessary skills for safe care. During an interview, the Director of Nursing (DON) was unable to provide the personnel file of a registry nurse involved in a reported incident, as the records were held by the staffing agency. Despite requests, the competency evaluation of the nurse was not obtained, and the DON was unaware of how the agency evaluated the nurses' skills. The Administrator confirmed that their contract with the staffing agency assumed the nurses had the required skills, but he was not familiar with the agency's evaluation process. The facility's policy on staff competency assessment did not include registry staff, and a specific policy for registry nurses was not provided. The lack of documentation and understanding of the evaluation process led to uncertainty about the competency of registry nurses working in the facility.
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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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