Santa Anita Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple City, California.
- Location
- 5522 Gracewood Ave., Temple City, California 91780
- CMS Provider Number
- 055293
- Inspections on file
- 116
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Santa Anita Convalescent Hospital during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, dementia, type 2 DM, and impaired decision-making capacity was prescribed Zyprexa 2.5 mg at bedtime for bipolar disorder manifested by screaming without cause. A Schizophrenia Diagnosis Checklist showed the resident did not meet criteria for schizophrenia, yet the consent form documented that the responsible party consented to Zyprexa for schizophrenia rather than bipolar disorder. The DON confirmed the discrepancy between the physician’s order and the consent form, despite a facility policy requiring that informed consent for psychotherapeutic drugs include disclosure of the correct reason for treatment and the nature of the illness.
A resident with Alzheimer’s disease, dementia, and type 2 DM was admitted with a POA identified and a long-standing primary care MD documented on a hospital face sheet, but the facility assigned a different attending MD without consulting the resident or POA. The Admissions Coordinator and Director of Marketing each acknowledged they did not speak with the POA or resident about physician choice and did not inform them of the assigned MD, assuming others would handle it. Facility policies on designation of attending physician and resident rights required that residents be asked to choose a personal MD prior to or upon admission and be informed when the facility designates one, but this process was not followed, resulting in the resident being placed under the care of a different MD without the POA’s knowledge or consent.
A resident with cataracts, muscle weakness, right arm pain, moderate cognitive impairment, and a documented high fall risk required supervision/touching assistance for ambulation per the MDS and care plan, which also directed staff to assist with transfers/locomotion and remind the resident to request help before walking. Despite this, the resident was allowed to walk independently outside a patio area while using a wheelchair like a walker, without staff present to supervise or assist. The resident lost balance, fell backward, and hit his head on the floor while attempting to grab the wheelchair, as confirmed by the resident, a respiratory therapist, and nursing staff, who acknowledged that required supervision and assistance were not provided at the time of the fall.
A resident with severe cognitive impairment, mobility limitations, and high fall risk did not have a person-centered care plan developed or implemented to address their need for supervision and assistance with ADLs. Despite assessments and staff confirming the need for substantial support, the facility failed to document or provide a care plan as required by policy.
A resident with cognitive impairment and significant physical disabilities was able to leave the facility unsupervised after a pedestrian assisted in opening a parking lot gate, which was remotely unlocked by a receptionist who did not verify the individual's identity. The resident was not accounted for during routine checks and was later found hospitalized after being missing for several hours. The facility did not follow its own procedures for monitoring and controlling access, resulting in the resident's elopement.
Surveyors identified that the facility did not maintain the building structure to prevent pest and rodent entry, including a tree branch touching the laundry roof, an open section of eaves, and gaps around drainpipes in the laundry area. Maintenance and environmental services staff acknowledged the issues, and pest control had previously recommended corrective actions that were not completed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
A resident with dementia and significant care needs was not monitored or assessed for 72 hours after an alleged physical abuse incident, as required by facility policy. Nursing staff did not document the resident's condition for multiple shifts following the event, despite the resident's inability to verbalize changes and the facility's established procedures for post-incident monitoring.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple medical conditions was served food items, including pasta and carrots, at temperatures below the facility's required standards. Observations and temperature checks confirmed that several food items on resident and test trays did not meet the policy's temperature requirements, and staff acknowledged the deficiency.
A dumpster in the back parking lot was observed overflowing with kitchen trash, including open food waste, and its lid was not closed. Staff confirmed the dumpster was smelly and surrounded by flies, and stated it should have been closed and not emitting odors. Facility policies require garbage to be properly contained and dumpsters to be kept closed and clean, which was not followed in this instance.
Two residents were found living in unsanitary conditions, including a dirty toilet seat with dried substances, cluttered and stained floors, a soiled towel left on a linen barrel, and an uncollected food tray. Staff acknowledged the room was dirty, and one resident expressed concern about the bathroom's cleanliness. Facility policy requires a clean and homelike environment, which was not maintained.
A resident with dementia, a history of falls, and muscle wasting was found with their call light on the floor and out of reach while needing assistance for a brief change. Staff confirmed the call light should have been accessible, as required by the care plan and facility policy, but it was not, preventing the resident from requesting help.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with a history of sexually inappropriate behavior and a physician's order for 1:1 supervision was not provided with a sitter, allowing the resident to sexually abuse another cognitively impaired resident. Prior incidents of inappropriate behavior were not properly reported or addressed, and required supervision was not implemented, leading to the abuse.
A resident with a history of wandering and violent behavior, who had a physician's order for 1:1 supervision, was not provided with a sitter as required. This lapse allowed the resident to enter the room of another cognitively impaired resident and commit a sexual assault, which was discovered by an LPN responding to a scream. The facility lacked a process to ensure sitter assignments were tracked and implemented, leading to the incident.
The facility did not ensure that most direct and indirect care staff received required in-service training on resident rights and facility responsibilities, as only a small portion of staff attended the scheduled session and there was no evidence of training for other shifts. Both the DSD and DSDC confirmed the training was incomplete, and facility policy requiring annual education and monitoring of attendance was not followed.
The facility did not provide required behavioral health training to 452 out of 552 direct and indirect care staff, as shown by incomplete attendance records and missing lesson plans. This deficiency affected staff knowledge and preparedness in caring for residents with behavioral health issues, particularly those housed in a secure dementia/behavioral unit.
A resident with moderate cognitive impairment and a history of psychiatric and behavioral issues engaged in sexually inappropriate behavior, which was observed by a 1:1 sitter. The incident was not promptly reported, and nursing staff did not develop or implement a care plan to address the behavior, contrary to facility policy. This failure placed other residents at risk.
A resident with intact cognitive abilities and multiple medical conditions repeatedly requested that certain individuals not visit and that her responsible party be changed. Despite these clear requests, staff did not update records or enforce her preferences, resulting in unwanted visits and emotional distress for the resident.
Two residents with severe cognitive impairment and high dependence for ADLs experienced falls due to lack of required supervision and assistance. One resident fell from bed when only one CNA provided care instead of the required two-person assist, while another resident with a physician's order for 1:1 supervision had an unwitnessed fall when no sitter was assigned during a shift.
A resident with multiple diagnoses, including Parkinson's disease and dementia, experienced significant weight loss that was not accurately documented on the MDS. The MDS nurse and DON confirmed the assessment did not reflect the resident's actual weight loss, contrary to facility policy requiring accurate documentation for care planning.
A resident with multiple complex medical conditions experienced significant weight loss, but staff did not complete a Change of Condition or implement the Registered Dietician's recommendations for nutritional interventions and physician notification, as required by facility policy.
A resident with a history of pneumonia, acute respiratory failure, and hemiplegia developed a skin rash and was prescribed Diphenhydramine HCl Cream 2% to be applied every eight hours as needed. Nursing staff failed to administer the medication for ten days, as confirmed by MAR review and staff interviews, despite the resident's continued symptoms and dependency on staff for care. The facility's policy required administration and documentation of medications per physician orders, which was not followed in this instance.
Three residents received antipsychotic medications without proper documentation of diagnoses, monitoring of target behaviors, or evidence that nonpharmacological interventions were attempted. For one resident, Quetiapine was given without supporting documentation for schizophrenia or monitoring of hallucinations. Another resident received Risperidone for behavioral symptoms without documentation of attempted NPIs, and staff reported no observed aggression. A third resident on Olanzapine was not properly monitored for behavioral symptoms as required, with medication records lacking necessary detail. Facility policies requiring behavioral monitoring and NPI use were not followed.
Nursing staff failed to verify the identity of two residents before administering medications and did not ensure that prescription labels for two other residents matched physician orders that included specific hold parameters for blood pressure and heart rate. These actions were inconsistent with facility policy, which requires identity verification and matching of physician orders, prescription labels, and the MAR prior to medication administration.
Two residents experienced medication errors when a nurse administered the wrong dose and form of docusate sodium to one resident and failed to check heart rate before giving amiodarone to another, resulting in a medication error rate above 5%. The nurse did not follow required procedures for resident identification and vital sign monitoring prior to medication administration, as confirmed by interviews and record review.
Surveyors found that a medication cart was left unlocked and unattended, and multiple medications for both current and discharged residents were not properly stored or labeled. Unused antibiotics for a discharged resident were not accounted for or destroyed as required, an unopened insulin pen was not refrigerated, and discontinued or bedhold medications remained in medication carts. Staff interviews confirmed these practices were not in line with facility policy.
Surveyors found that kitchen staff failed to clean can openers after use, left apple bar trays uncovered on a cooling rack, and used a cracked food tray with exposed rusted metal. Staff interviews confirmed these lapses, which were not in accordance with facility policies for food handling and storage.
Staff failed to label and date food items brought in by visitors for a resident, as required by facility policy. Unlabeled items, including ice cream, coffee, ice, and soda, were found in a staff breakroom refrigerator. Staff interviews confirmed the lack of labeling, which was not in compliance with the facility's procedures for handling outside food.
Six dumpsters in the back parking lot were found overflowing and not closed, containing facility and kitchen trash in clear and black plastic bags. The dietary director and an LVN confirmed that dumpsters should not be overflowing and must be closed to prevent attracting pests. Facility policy requires food waste to be placed in covered garbage and trashcans.
Three residents with cognitive and physical impairments did not receive required assistance with ADLs, including oral care, access to a communication board, and fingernail hygiene. One resident was observed with dry, cracked lips due to missed oral care, another was unable to communicate needs because a communication board was not available, and a third had dirty fingernails with fecal matter. Staff interviews and observations confirmed these lapses, despite facility policies requiring such care.
Staff did not consistently wear required PPE when entering rooms under contact precautions, and enhanced barrier precaution signage and supplies were missing for a resident with MDROs and an indwelling device. Additionally, respiratory equipment for two residents was not changed weekly as ordered, with items observed to be several weeks overdue for replacement.
Staff did not ensure privacy for a dependent resident during incontinent care by leaving the curtain and door open, and another resident was provided a cracked, chipped water pitcher with sharp edges. Both incidents failed to uphold resident dignity and respect as required by facility policy.
Two residents with significant medical needs and mobility limitations did not have their call lights within reach, as observed by staff. In both cases, the call lights were found on the floor and inaccessible, despite facility policy requiring that residents have access to a call system for assistance.
A resident with hemiplegia, hemiparesis, and cognitive impairment was found sleeping with their face against side rail pads that were visibly soiled with old food stains. Staff confirmed the pads were dirty, and the facility's infection control policy required daily disinfection. This failure created an unsanitary environment and potential infection risk.
A resident with multiple diagnoses and severe cognitive impairment was receiving physician-ordered oxygen therapy, which was consistently administered and documented in the MAR, but this therapy was not reflected on the MDS assessment. The MDS nurse acknowledged the omission, and facility policy requires accurate use of the RAI process for resident assessments.
A resident with multiple psychiatric and neurological diagnoses was prescribed Seroquel, but the care plan was not updated or revised to reflect current diagnoses or include nonpharmacological interventions. Staff and a psychiatrist noted inconsistencies in the resident's documented conditions, and the facility did not follow its policy requiring individualized, updated care plans for psychotropic medication use.
Two residents did not receive proper G-tube care, including failure to elevate the head of bed during tube feeding as ordered by a physician and failure to maintain a clean valve on the G-tube. Staff confirmed these lapses, and the facility lacked a specific policy for valve maintenance, despite having a general infection control program.
A resident receiving hemodialysis did not have consistent and complete documentation of their AV shunt access site assessments, as required by facility policy. Multiple dialysis communication records were found to be incomplete, lacking necessary information about infection signs and vascular access status. Nursing leadership confirmed that incomplete records were not followed up with the dialysis center, leading to gaps in care documentation.
A resident with depression and suicidal ideation did not receive required one-to-one sitter supervision as ordered and care planned. Despite clear documentation and facility policy mandating immediate supervision, no staff were assigned to sit with the resident during the night shift, and staff were unaware of the requirement. The lack of implementation was confirmed by direct observation and staff interviews.
A resident with documented dislike of pasta was repeatedly served meals containing pasta or noodles, despite her care plan and dietary profile specifying this preference. Staff failed to clarify the resident's definition of pasta, resulting in her receiving unwanted food items and expressing dissatisfaction with her meals.
A resident with multiple health conditions, including COPD, had a physician's order for oxygen therapy as needed. Observations and staff interviews revealed that oxygen was not set up or administered, yet the MAR inaccurately documented that oxygen was given over several days. Multiple nurses confirmed the documentation was incorrect, failing to meet the facility's policy for accurate nursing records.
A resident signed an arbitration agreement that did not include required information about the use of a neutral arbitrator or the selection of a venue convenient to both parties. Staff members were unaware of the need to provide this information, and the facility had recently adopted a shortened agreement form that omitted these details, resulting in an incomplete understanding of the agreement for the resident.
Surveyors found that two residents were exposed to unsafe conditions due to exposed bed control and call light wires, and an overflowing trash can with used PPE was observed in a resident room. Staff interviews confirmed these conditions were not acceptable and did not follow facility policy for maintaining a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and behavioral issues tipped over the wheelchair of another resident with dementia and Parkinson's Disease, causing the latter to fall and sustain a minor head injury. Staff and documentation confirmed the incident was witnessed and that the resident responsible was not adequately monitored, resulting in a failure to protect residents from abuse as required by facility policy.
A resident with severe cognitive impairment and multiple medical conditions was found to have a low air loss mattress set at a weight significantly lower than their actual weight, contrary to physician orders and facility policy. Staff and DON confirmed the setting was incorrect, which did not align with the resident's care plan for pressure ulcer prevention.
A resident with a history of falls and high fall risk was observed attempting to get out of bed while the bed casters were left unlocked, causing the bed to move. The ADON confirmed the casters were not locked, contrary to facility policy and manufacturer instructions, which require bed brakes to be engaged to prevent involuntary movement and potential injury.
Failure to Obtain Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain accurate informed consent for the use of the antipsychotic medication Zyprexa for a resident. The resident was admitted and later readmitted with diagnoses including Alzheimer's disease, dementia, and type 2 DM, and an MDS assessment showed moderately impaired cognitive skills and a need for assistance with activities of daily living. A Schizophrenia Diagnosis Checklist dated 2/12/2026 indicated the resident did not meet criteria for schizophrenia. However, the History & Physical dated 2/25/2026 documented a present illness of bipolar disorder and stated the resident did not have the capacity to understand and make decisions. On 2/25/2026, the physician's order directed Zyprexa 2.5 mg by mouth at bedtime for bipolar disorder manifested by screaming without cause. The facility’s consent form, also dated 2/25/2026, documented that the resident’s responsible party was made aware of and consented to Zyprexa 2.5 mg for a diagnosis of schizophrenia with the behavior of screaming without cause, rather than for bipolar disorder as written in the physician’s order. In an interview, the DON confirmed that the consent obtained was for schizophrenia and not for bipolar disorder, and stated it was important to obtain the correct consent so the resident and responsible party would know and be able to choose the appropriate treatment plan. The facility’s informed consent policy required that the attending physician disclose the reason for treatment and the nature and seriousness of the resident’s illness when obtaining informed consent for therapies including psychotherapeutic drugs.
Failure to Honor Resident’s Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose an attending physician prior to or upon admission, as required by facility policy. The resident was admitted with diagnoses including Alzheimer’s disease, dementia, and type 2 DM, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of assistance with ADLs. The admission record listed a specific physician (MD 3) as the primary physician, while a face sheet faxed from a general acute care hospital identified a different physician (MD 1) as the resident’s primary care physician. The resident’s POA (RP 1) was identified in the admission record, but neither the resident nor RP 1 was asked to choose an attending physician at or before admission. RP 1 reported not being informed that MD 1 was not the attending physician until a change of condition occurred, and stated she was never told the resident would be assigned a new physician or asked about her choice, despite MD 1 having been the resident’s primary physician for over 10 years. The Admissions Coordinator acknowledged assigning the resident to MD 3 without asking RP 1 about physician choice and did not notify RP 1 of the change, stating it was not her responsibility. The Director of Marketing stated that when the referral was received, she assigned the resident to one of the facility doctors without speaking to the resident or RP 1 about their choice of attending physician and did not follow up, assuming another staff member would do so. Review of the facility’s policies on Designation of Attending Physician and Resident’s Rights confirmed that residents must be asked to choose a personal attending physician prior to or upon admission and be informed when the facility designates one, which did not occur in this case, as acknowledged by the Administrator.
Failure to Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall for a resident assessed as high risk for falls. The resident had diagnoses including cataract, muscle weakness, and right arm pain, and an MDS dated 10/24/2025 documented moderately impaired cognitive skills for daily decision-making. The MDS also indicated the resident required supervision/touching assistance for ambulation (walking 10 feet, 50 feet with two turns, and 150 feet) and setup/cleanup assistance for toileting hygiene, lower body dressing, footwear, and personal hygiene. The resident’s fall risk assessment dated 12/3/2025 identified the resident as high risk for falls. The care plan for fall risk, revised 10/30/2025, directed staff to provide assistance with transferring and locomotion as needed and to educate/remind the resident to request assistance prior to transfer/ambulation. A separate care plan for elopement risk, also revised 10/30/2025, instructed staff to address wandering behavior by walking with the resident and to evaluate the need for additional supervision. On 12/16/2025, the resident experienced a witnessed fall outside the patio area while entering another unit, during which the resident fell backward and hit his head on the floor. Progress notes from that date at 9:00 AM documented that the resident fell outside the patio area while entering another unit and fell backward while trying to grab his wheelchair. In an interview, the resident stated he had been walking by himself while pushing the wheelchair when he fell outside the unit. A respiratory therapist reported observing the resident using his wheelchair like a walker, losing balance, and falling backward while she was only present to open the door and was not supervising the resident; she confirmed the resident was by himself at the time of the fall. The RN supervisor and QA nurse both confirmed that, based on the MDS and care plan, the resident required supervision/touching assistance when walking, meaning a person should be with the resident to guide and help as needed, and acknowledged that no one was with the resident and he did not have the required assistance at the time he was ambulating and fell. Facility policies on fall management, care planning, and safety of residents required development and implementation of care plans and provision of a safe environment, but the resident was allowed to ambulate without the indicated supervision and assistance when the fall occurred.
Failure to Develop and Implement Person-Centered Care Plan for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for one resident who required supervision and assistance with Activities of Daily Living (ADLs). The resident had multiple diagnoses, including lack of coordination, difficulty walking, dementia, and Parkinson's Disease, and was assessed as having severely impaired cognitive skills and high dependency for various ADLs such as toileting, bathing, dressing, and transfers. Multiple assessments, including the Minimum Data Set and Fall Risk Assessments, indicated the resident was at high risk for falls and required substantial to maximal assistance or supervision for mobility and transfers. Interviews with staff, including a CNA and the Director of Rehab, confirmed the resident needed supervision or touching assistance during walking and transfers. Despite these documented needs and facility policy requiring comprehensive, person-centered care plans, a review of the resident's medical chart revealed no care plan addressing the need for supervision or assistance with ADLs. Staff interviews, including with an LVN and the DON, confirmed that no specific care plan had been developed or implemented for this resident's supervision or assistance needs. The facility's policy emphasized the importance of individualized care planning involving the interdisciplinary team, but this process was not followed for the resident in question.
Failure to Supervise and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to supervise and ensure the safety of a resident in accordance with its Wandering and Elopement Policy and Procedure. The resident, who had chronic obstructive pulmonary disease, chronic pulmonary edema, and bilateral below-the-knee amputations, was moderately cognitively impaired and required significant assistance with activities of daily living. Despite these needs, the resident was able to leave the facility unsupervised through a parking lot gate after an unknown pedestrian pressed the gate button, which was then opened by the receptionist without verifying the identity or purpose of the individual at the gate. The resident was last seen in the facility's patio area in the afternoon and was not accounted for during routine checks by staff. Multiple staff interviews revealed that the resident was not observed returning to his room at the usual time, and there was uncertainty among staff regarding supervision responsibilities in the patio area. The facility's security camera footage later confirmed that the resident exited the facility through the parking lot gate with the assistance of a pedestrian, and staff did not realize the resident was missing until several hours later during shift change and meal distribution. The receptionist, who was responsible for monitoring the parking lot gate, did not follow the facility's protocol to verify the identity of individuals requesting access. This lapse allowed the resident to leave the premises undetected. The resident was eventually found by a neighbor and admitted to a general acute care hospital with decompensated congestive heart failure and pleural effusion after being exposed to the outside environment for an extended period. The facility's failure to provide adequate supervision and to follow established procedures directly led to the resident's elopement and subsequent hospitalization.
Failure to Maintain Building Structure and Prevent Pest Entry
Penalty
Summary
The facility failed to maintain the building structure in a manner that prevented possible entry points for pests and rodents. Observations revealed a tree branch with foliage was in direct contact with the roof structure of the laundry department, creating a pathway for pests and rodents to access the facility. Additionally, a section of the eaves outside the laundry department, measuring 30 inches by 4 inches, was left open without a wood cover or frame, further increasing the risk of pest and rodent entry. Inside the laundry room, a metal frame on the floor surrounding two drainpipes had large gaps and holes, providing additional access points for pests and rodents. Interviews with the Maintenance Supervisor and Environmental Services Director confirmed awareness of the issues, with both acknowledging the importance of maintaining the facility structure and following pest control recommendations. The pest control service report had previously identified the vegetation contact as a risk and recommended trimming, but this action was not completed. The facility's policy and procedure indicated that the maintenance department is responsible for ensuring the safety and operability of the building, grounds, and equipment at all times to protect the health and safety of residents, visitors, and staff.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events, observations, or resident conditions related to the incident.
Failure to Monitor and Document Resident After Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was assessed and monitored for 72 hours following an alleged incident of physical abuse, as required by the facility's policy and procedure. The resident, who had diagnoses including adult failure to thrive, dementia, and weakness, was dependent on staff for most activities of daily living and had moderately impaired cognitive skills. After an alleged episode of physical abuse by a certified nurse assistant, the care plan was updated to include regular assessment of the resident's emotional status. However, a review of the medical records revealed that there was no documentation of monitoring for the resident's condition during all shifts on the day following the incident. Interviews with nursing staff and facility leadership confirmed that 72-hour monitoring and documentation should have been completed for each shift, especially given the resident's inability to verbalize changes in condition. The facility's policy required licensed nurses to document the resident's status every shift for at least 72 hours after a change in condition, but this was not done. The absence of monitoring and documentation was acknowledged by multiple staff members, including the Director of Nursing, who confirmed that the required assessments were not performed as per policy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food at the proper temperatures as required by its policy and procedure titled Food Temperatures. During an interview, a resident reported that her food was usually served cold. Observation and temperature checks confirmed that the food items served to the resident, including pasta and carrots, were below the required serving temperature of more than 140 degrees Fahrenheit, with the pasta at 123°F and carrots at 108°F. Additional test trays also showed food items, such as chicken and rice casserole and carrots, being served below the required temperature, and milk being served above the acceptable cold temperature of less than 41°F. The resident involved had a medical history including diabetes mellitus, hypertension, and depression, and required varying levels of assistance with activities of daily living, including setup or clean up assistance with eating. Both the Quality Assurance Nurse and the Administrator confirmed that the food temperatures did not meet the facility's policy requirements at the time the food was served to the resident. The facility's policy specified that food not meeting the required temperatures should be reheated or chilled to the proper temperature before serving, which was not done in this instance.
Improper Disposal and Overflowing Dumpster
Penalty
Summary
During an observation, one of two dumpsters located in the facility's back parking lot was found to be overflowing, with its lid not closed. The dumpster contained kitchen trash, including crushed eggshells in an open box, and emitted a strong odor of spoiled or rotten food. Flies were visibly present around the dumpster. Staff interviews confirmed that the dumpster was overflowing, smelly, and surrounded by flies, and that it should have been closed and not emitting odors. The Dietary Director and Dietary Aid both stated that dumpsters are supposed to be closed at all times and that kitchen trash should be double-tied in plastic bags before being placed in the dumpster to prevent attracting insects and rodents. A review of the facility's policies and procedures revealed that garbage and trash cans are to be used according to manufacturer guidelines, cleaned routinely, and that food waste should be placed in covered garbage and trash cans. The pest control policy also indicated that garbage and trash are not permitted to accumulate in any part of the facility. The observed practice of leaving the dumpster overflowing and uncovered, with improperly disposed food waste, was not in accordance with these policies.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two of three sampled residents by not ensuring the cleanliness and orderliness of their living space. Observations and interviews revealed that the toilet seat in the residents' room had brownish to reddish dry substances, and the floor was cluttered with empty cups, cup covers, food wrappers, and food stains. Additionally, a dirty white towel with a brownish substance was found placed on top of a covered linen barrel instead of inside it, and an old food tray from dinner had not been picked up. Both the housekeeping staff and the assistant administrator acknowledged the room was dirty, with the assistant administrator specifically noting the presence of dry feces on the toilet seat and the potential for the environment to harbor bacteria and attract pests. Resident records indicated that one resident had intact cognitive skills while the other had severely impaired cognitive skills, both with medical histories including diabetes and a history of falls. The infection preventionist nurse confirmed that food should have been removed after meals, towels should be properly stored for infection control, and the floor and toilet should be kept clean. One resident expressed concern about the unclean bathroom and the possibility of becoming ill as a result. The facility's policy and procedures require staff to maintain a safe, clean, and homelike environment, which was not followed in this instance.
Call Light Not Kept Within Reach for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by the facility's policy and the resident's care plan. The resident, who had diagnoses including dementia, a history of falls, and muscle wasting, was assessed as being at high risk for falls and required varying levels of assistance with daily activities. The care plan specifically indicated that the call light should be attached and within reach, and the facility's policy also required the call light to be accessible to residents. During an observation, the resident's call light was found on the floor, out of reach, while the resident was attempting to indicate a need for a brief change. Staff interviews confirmed that the call light should not have been on the floor and that the resident knew how to use it to request assistance. The failure to keep the call light within reach meant the resident was unable to call for help when needed, contrary to both the care plan and facility policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Provide Required Supervision Resulting in Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from sexual abuse by another resident. The resident who committed the abuse had a physician's order for one-to-one (1:1) supervision due to wandering and sexually inappropriate behaviors, but was not provided with a sitter during the night shift. This lack of supervision allowed the resident to enter another resident's room and commit sexual abuse, which was discovered by a nurse responding to a scream. The nurse found the perpetrator on top of the victim, whose pants and diaper were pulled down above the knees. The incident was confirmed by multiple staff interviews and documentation. Prior to the incident, there were documented episodes of the perpetrating resident engaging in sexually inappropriate behavior, such as playing with his private area. These behaviors were observed by certified nursing assistants but were either not reported promptly to licensed staff or not documented and addressed according to facility policy. The facility's change of condition policy required that such behaviors be reported to the physician, monitored, and documented, but this was not done. The lack of timely reporting and intervention meant that no new or updated interventions were developed to prevent further incidents. The victim was a resident with severe cognitive impairment, requiring significant assistance with daily activities and supervision for safety. The perpetrator had a history of paranoid schizophrenia, violent behavior, and was HIV positive. The failure to provide required supervision and to act on prior sexually inappropriate behaviors directly led to the incident of sexual abuse. Staff interviews confirmed that the required 1:1 supervision was not in place at the time of the incident, and that there was no process to ensure compliance with sitter assignments.
Failure to Provide 1:1 Supervision Results in Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for a resident with a known history of wandering and behavioral issues. One resident, diagnosed with paranoid schizophrenia, violent behavior, and HIV, was assessed as having a significant risk for wandering and had a physician's order for a 1:1 sitter to provide constant supervision. Despite this order, the resident was not assigned a 1:1 sitter during the overnight shift, and there was no process in place, such as a sitter log, to ensure compliance with the order. As a result of this lack of supervision, the resident with wandering behavior entered the room of another resident who had severe cognitive impairment due to dementia, depression, and schizophrenia. The cognitively impaired resident required substantial assistance with daily activities and was unable to protect herself. During the incident, the resident with wandering behavior was found on top of the other resident, whose pants and diaper were pulled down, and he admitted to having sex with her. Staff interviews and record reviews confirmed that the 1:1 sitter was not provided as ordered, and the facility's policies required that physician orders be carried out completely and that residents be protected from abuse. The absence of a sitter and lack of monitoring directly led to the incident, which was discovered when a nurse responded to a scream and found the resident in the act. The event was reported to supervisory staff, law enforcement, and other relevant authorities.
Failure to Provide Resident Rights Training to Majority of Staff
Penalty
Summary
The facility failed to ensure that the majority of its staff, specifically 524 out of 552 direct and indirect care staff, received in-service training on resident rights and facility responsibilities as required by facility policy. Record review showed that the Resident Rights in-service was scheduled for April 2025, but attendance records indicated that only 28 staff members attended, primarily from the night shift. There were no sign-in sheets or evidence of training for the other shifts, and both the Director of Staff Development (DSD) and the Staff Development Consultant (DSDC) confirmed that the in-service was not provided to all staff. The DSD stated it was not possible to keep track of all staff attendance, and the DSDC acknowledged the significant impact this lack of training could have on residents. Interviews with the DSD and DSDC further revealed that the facility's policy requires annual and as-needed training on resident rights for all staff, and that department heads are responsible for ensuring staff attendance at mandatory in-services. The DSD admitted that incomplete in-service attendance meant staff might be unaware of critical information regarding resident rights, including the right not to be abused and the right to receive or decline care. The facility's policy also states that lack of staff attendance should be reported to the administrator and department heads, but this process was not followed, resulting in a deficiency in staff education on resident rights.
Failure to Provide Behavioral Health Training to Majority of Staff
Penalty
Summary
The facility failed to provide behavioral health training to 452 out of 552 direct and indirect care staff, as required by the facility assessment and policy. Record reviews showed that the annual in-service calendar scheduled behavioral health training for November, but attendance records from the December in-service indicated that only 100 staff, primarily from the morning shift, participated. There was minimal representation from the evening shift and only one night shift staff attended, leaving the majority of staff without the required training. The Director of Staff Development confirmed that no follow-up was conducted to ensure all shifts received the training, and the Director of Nursing acknowledged the absence of a lesson plan in the in-service binder, further indicating the training was incomplete. Interviews with staff, including a CNA and an LVN, revealed that the lack of behavioral health in-service could impact their ability to provide appropriate care and identify resident behaviors. The facility's policies require the Director of Staff Development to assess educational needs, plan and implement training, and maintain attendance records with lesson plans, but these requirements were not met. The facility assessment identified a secure unit for residents with dementia or behavioral issues, highlighting the importance of this training for the 49 residents with behavioral health concerns.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's sexually inappropriate behavior, specifically the act of touching his private area and making inappropriate requests to a staff member. The resident, who had diagnoses including paranoid schizophrenia and violent behavior, was assessed as having moderate cognitive impairment and required supervision for several activities of daily living. Despite an incident being observed and reported by a 1:1 sitter, there was a delay in reporting the behavior to nursing staff, and no care plan interventions were initiated to address the inappropriate sexual behavior. Interviews with nursing staff confirmed that the incident should have been reported immediately and that a resident-centered care plan should have been developed and implemented to ensure the safety of the resident and others. A review of facility policy indicated that care plans must be updated to address changes in behavior, but this was not done following the incident. The lack of timely reporting and failure to initiate appropriate care planning placed other residents at risk.
Failure to Honor Resident's Rights to Visitor Choice and Responsible Party
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choice and to designate her own responsible party. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and required dialysis, was cognitively intact and capable of making her own decisions. Despite multiple documented requests from the resident to restrict visits from certain individuals and to change her responsible party to another person, these requests were not acted upon by facility staff. Documentation in the resident's records, including social services notes and interdisciplinary team notes, showed that the resident repeatedly expressed her desire not to have visits from specific visitors and to have a different responsible party involved in her care. The resident also communicated her wishes directly to staff members, including certified nursing assistants and social services staff, and requested that her medical records be updated to reflect these changes. However, the facility did not update the records or enforce the resident's preferences, resulting in unwanted visits and continued involvement of the previously designated responsible party. During interviews and observations, the resident stated she felt unsafe and uncomfortable due to the facility's failure to respect her choices regarding visitors and responsible party. Staff confirmed that the resident had the capacity to make these decisions and that her requests should have been honored. The facility's own policy required staff to respect residents' rights to self-determination and to document personal preferences, but these procedures were not followed in this case.
Failure to Provide Adequate Supervision and Assistance Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate safety and supervision for two out of three sampled residents, resulting in falls. For one resident with diagnoses including dementia, osteoporosis, metabolic encephalopathy, muscle weakness, and a recent right femur fracture, the Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for all activities of daily living (ADLs). On the evening of 2/17/2025, a Certified Nurse Assistant (CNA) provided bed mobility, dressing, and personal hygiene care to this resident without the assistance of a second staff member, despite facility policy and staff interviews confirming that a two-person assist was required for such dependent residents. During this care, the resident rolled off the bed and fell. Another resident, admitted with cerebral ischemia, dementia, and a history of facial fractures from a previous fall, also had severely impaired cognition and required varying levels of assistance for ADLs. Following a physician's order for continuous one-on-one supervision (1:1 sitter) after a fall, the facility failed to document or provide evidence that a sitter was assigned during a specific shift. On 4/28/2025, this resident experienced an unwitnessed fall and was found on the floor, despite the order for a 1:1 sitter and a bed alarm. Review of staffing assignments confirmed the absence of a designated sitter during the relevant shift. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the required supervision and assistance were not provided according to the residents' care plans and physician orders. Facility policies reviewed emphasized the need for appropriate staff assistance and supervision to prevent falls, but these were not followed in the cases described, directly leading to the residents' falls.
Failure to Accurately Document Resident Weight Loss on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's weight loss on the Minimum Data Set (MDS) as required by facility policy. Specifically, a resident with diagnoses including Parkinson's disease, dementia, type 2 diabetes mellitus, and dysphagia experienced a significant weight loss, dropping from 163 pounds to 149 pounds within a month, which equates to an 8.59% loss. Over a six-month period, the resident lost 19% of their body weight. However, the MDS did not reflect this weight loss, incorrectly indicating that the resident had not lost 5% or more in the last month or 10% or more in the last six months. During interviews, the MDS nurse acknowledged that the MDS was inaccurate and should have documented the resident's weight loss. The DON also confirmed that the MDS should accurately reflect weight loss to enable the development of an appropriate care plan and to monitor trends. Facility policy requires that all information recorded in the MDS must reflect the resident's status at the time of the assessment, but this was not followed in this case.
Failure to Address Significant Weight Loss and Follow Dietician Recommendations
Penalty
Summary
The facility failed to provide appropriate nutritional care and services for one resident who experienced significant weight loss. Despite documented weight loss of 8.59% in one month and 19% over six months, the facility did not complete a Change of Condition (COC) or follow the Registered Dietician's (RD) recommendations. The RD had advised a referral to the physician for blood sugar monitoring, the addition of sugar-free home parenteral nutrition and Boost Glucose Control, and lab orders. However, there was no evidence in the medical records that these recommendations were implemented, nor was there documentation of physician notification or follow-up actions. Interviews with facility staff, including the RD, MDS nurse, and Director of Nursing, confirmed that the expected protocol was not followed. The facility's policy required notification of the attending physician and completion of a COC for significant weight changes, but these steps were not taken. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, type 2 diabetes, and dysphagia, and required substantial assistance with daily activities. The failure to act on the RD's recommendations and to complete required documentation constituted a deficiency in the facility's nutritional care practices.
Failure to Administer Ordered Topical Medication for Skin Rash
Penalty
Summary
A deficiency occurred when nursing staff failed to administer Diphenhydramine HCl Cream 2% as ordered by a physician for a resident with a documented skin rash. The resident, who was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, and hemiplegia, was noted to have a rash on the right arm, left chest, and left leg. The physician ordered the topical medication to be applied every eight hours as needed for the rash, but review of the Medication Administration Record (MAR) showed that the medication was not administered for a period of ten days. Interviews with the resident and the treatment nurse confirmed that the cream was not applied during this time, and the nurse acknowledged that the medication should have been given as ordered. The resident's cognitive skills were moderately impaired, and they were dependent on staff for personal care. During the period when the medication was not administered, the resident continued to have rashes, as observed by the treatment nurse. The facility's policy required medications to be administered and documented per physician orders, but this was not followed in this case. The Director of Nursing confirmed that the medication was not given as ordered and acknowledged the importance of following physician instructions for medication administration.
Failure to Prevent Unnecessary Use of Psychotropic Medications and Chemical Restraints
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that three of five sampled residents were free from chemical restraints. For one resident, Quetiapine (Seroquel) was administered without proper monitoring of target behaviors, without clinical documentation supporting a diagnosis of schizophrenia, and without evidence that nonpharmacological interventions (NPI) were attempted or provided. Interviews with facility staff and a psychiatrist revealed that the resident did not exhibit hallucinations or delusions, and there was no clear documentation of schizophrenia in the clinical record. Nursing progress notes and medication administration records showed zero episodes of the target behavior, and staff acknowledged that NPI interventions were not documented or implemented prior to or during the use of the antipsychotic medication. Another resident continued to receive Risperidone (Risperdal) for a diagnosis of bipolar disorder manifested by hitting staff during care, but there was no documentation of NPI interventions attempted or provided. Staff interviews indicated that the resident was generally calm, did not display physical aggression, and responded well to familiar caregivers. Review of the resident's care plan and medication records confirmed the absence of NPI monitoring or documentation, and staff stated that such interventions should have been implemented to address the resident's behaviors. A third resident was prescribed Olanzapine for psychosis manifested by striking out during care, but the facility failed to monitor the resident's behavior as required by the care plan and physician's order. The medication administration record only indicated yes/no responses for suicidal ideation without quantifying the frequency of behaviors, making it difficult to assess the effectiveness of the medication or the need for dose adjustments. The facility's policies required monitoring and documentation of behaviors and the use of nonpharmacological interventions, but these were not followed for the residents in question.
Failure to Verify Resident Identity and Match Prescription Labels with Physician Orders During Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents by not properly verifying resident identity and by not ensuring that prescription labels matched physician orders with specific administration parameters. During medication passes, two licensed vocational nurses (LVNs) administered medications to two residents without using appropriate identifiers to confirm their identities. In both cases, the nurses either called the resident by name or responded to a resident's request for medication but did not check identification bracelets or ask the residents to state their names, as required by facility policy. Both residents confirmed that their identities were not verified prior to receiving their medications. Additionally, the facility did not ensure that prescription labels for two other residents matched the physician orders, which included specific parameters for holding blood pressure or heart rate medications. For one resident, the physician's order for Spironolactone included instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm, but the prescription label did not reflect these parameters. Similarly, another resident's order for Amiodarone included a hold parameter for heart rate below 60 bpm, which was also missing from the prescription label. In both cases, the nurses acknowledged the discrepancies between the physician orders, the medication administration record (MAR), and the prescription labels. The facility's policy and procedures require verification of resident identity before medication administration and mandate that the prescription label, physician order, and MAR must match, with any discrepancies resolved prior to administration. The Director of Nursing confirmed that these steps are necessary to prevent medication errors and ensure safe medication practices. However, observations and interviews revealed that these procedures were not consistently followed, resulting in the identified deficiencies.
Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors identified out of 33 observed opportunities, resulting in a 6.06% error rate. In the first instance, a nurse administered the incorrect dose and form of docusate sodium to a resident. The resident was ordered to receive docusate sodium 100 mg oral tablet four times daily, but instead received a 250 mg capsule. The nurse did not verify the resident’s identity through standard procedures such as checking the identification bracelet or confirming the resident’s name and date of birth prior to administration. The nurse later acknowledged the error and confirmed that the medication given did not match the physician’s order. In the second instance, a nurse failed to check a resident’s heart rate prior to administering amiodarone 200 mg, as required by the physician’s order, which specified to hold the medication if the heart rate was less than 60 bpm. The nurse stated that vital signs were checked earlier in the morning but were not documented until after medication administration. The nurse admitted that the heart rate should have been checked immediately before giving the medication, in accordance with the order’s parameters. The resident’s care plan and physician’s order both indicated the necessity of monitoring vital signs prior to administration of cardiac medication. Both incidents were observed during medication administration and were confirmed through interviews with the involved nurse and the Director of Nursing. The facility’s policy and procedures require that medications be administered only as prescribed, with proper resident identification and completion of any required vital sign checks prior to administration. The observed practices did not align with these requirements, resulting in the cited deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that one of four medication carts (Unit A medication cart 1) was left unlocked and unattended, contrary to the facility's policies and procedures regarding medication security. The administrator confirmed the cart was unlocked with no staff present, and a Licensed Vocational Nurse (LVN) admitted to forgetting to lock the cart when leaving to attend to a resident. Interviews with other nursing staff confirmed that medication carts are required to be locked at all times when unattended to prevent unauthorized access. Further observations and interviews revealed that medications and biologicals were not properly stored or labeled for several current and discharged residents. For one discharged resident, an antibiotic bubble pack with remaining doses was found in a medication cart, and staff could not account for all doses or provide documentation of their destruction. The facility's policy requires unused medications to be removed from storage and destroyed in the presence of two licensed healthcare professionals, with proper documentation, but this process was not followed. Additional deficiencies included improper storage of an unopened Lantus SoloStar insulin pen, which was found at room temperature in a medication cart instead of being refrigerated as required by manufacturer instructions. Multiple discontinued, controlled, and bedhold medications for residents who were either transferred or discharged were also found stored in medication carts alongside active medications. Staff interviews confirmed that these medications should have been removed from the carts and stored separately or destroyed according to facility policy.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Surveyors observed multiple failures in food handling practices within the facility's kitchen. Two can openers were found to be dirty, with visible food residue and sticky gunk, including remnants of tomato sauce. Staff interviews confirmed that the can openers were not cleaned after use, contrary to facility policy, which requires sanitization between uses. Additionally, two trays of apple bar were observed on a cooling rack in the walk-in refrigerator without being fully covered, as required by the facility's food storage policy. Staff acknowledged that the trays should have been properly sealed to prevent contamination. Further inspection revealed a food tray with a crack exposing rusted metal, which was confirmed by both the Dietary Director and a dietary aide. Facility policy mandates that chipped or cracked service ware be discarded to maintain a sanitary environment. Staff interviews reiterated the importance of covering food properly and discarding compromised trays to prevent contamination and ensure safety. Review of relevant facility policies confirmed that these practices were not followed as required.
Failure to Label and Date Resident Food Brought in by Visitors
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the labeling and storage of food items brought in by visitors for residents. During an observation in the Unit B staff breakroom, several food items, including ice cream, coffee, ice, and soda, were found in the refrigerator without labels indicating the resident's name or the date the items were brought in. Interviews with the assistant director of nursing (ADON) and a registered nurse confirmed that these items were not labeled as required by facility policy. A review of the facility's policy titled 'Food Brought in by Visitors' revealed that all food from outside sources should be stored in sealable containers labeled with the resident's name and the date the food was brought in. The policy also specified that perishable food should be discarded after two hours at bedside, and if refrigerated, it should be labeled, dated, and discarded after 48 hours. The failure to label these items was acknowledged by staff and was not in accordance with the established procedures.
Improper Disposal and Overflowing Dumpsters
Penalty
Summary
Six dumpsters located in the facility's back parking lot were observed to be overflowing and not properly closed. During observations and interviews, the dietary director confirmed that the dumpsters contained both facility and kitchen trash in clear and black plastic bags and acknowledged that the dumpsters were not supposed to be overflowing. The dietary director and a licensed vocational nurse both stated that dumpsters and trashcans should not be overflowing and must be closed properly to prevent attracting rodents, flies, and insects. A review of the facility's policy and procedure on garbage and trashcan use and cleaning indicated that food waste should be placed in covered garbage and trashcans.
Failure to Assist Residents with ADLs, Oral Care, Communication, and Hygiene
Penalty
Summary
Three residents with significant cognitive and physical impairments did not receive necessary assistance with activities of daily living (ADLs), as observed and documented by surveyors. One resident, who had dementia, diabetes, and depression, was found to be totally dependent on staff for oral hygiene and personal care. Despite care plan instructions for daily oral care, this resident was observed with dry, scaly, and cracked lips, and staff interviews confirmed that oral care was not consistently provided. Another resident, with a history of stroke, emphysema, and failure to thrive, had a care plan indicating the need for a communication board due to a language barrier and severely impaired decision-making skills. During observation, the resident attempted to communicate needs through gestures, but the communication board was not available in the room, and staff were unable to understand the resident’s requests. Staff interviews confirmed that the communication board, which was supposed to be accessible, was not present. A third resident, admitted with sepsis, dysphagia, and muscle weakness, was also found to require substantial assistance with personal hygiene. Observations revealed that this resident’s fingernails were dirty and crusted, with black fecal matter present under the nails. Staff acknowledged the poor condition of the resident’s nails and the need for regular cleaning, as outlined in facility policy. Facility policies reviewed by surveyors emphasized the importance of grooming, infection control, and resident dignity, but these were not followed in the care of these residents.
Failure to Follow Infection Control Protocols and Equipment Change Procedures
Penalty
Summary
Facility staff failed to consistently follow infection prevention and control measures as outlined in facility policy and procedure. Staff did not don full personal protective equipment (PPE), including gown and gloves, before entering contact isolation rooms for several residents with active or historical multidrug-resistant organism (MDRO) infections. Observations showed that staff entered rooms with posted contact precautions signage without wearing required PPE, and interviews confirmed that staff were aware of the expectations but did not always comply. The infection preventionist and quality assurance staff acknowledged that the entire room should be treated as contact isolation when any resident in the room is on such precautions, and that PPE must be donned prior to entry regardless of the intended activity inside the room. Additionally, the facility did not ensure that enhanced barrier precaution (EBP) signage and PPE supply carts were present and available for residents requiring EBP due to indwelling devices or colonization with MDROs. In one case, a resident with a history of ESBL and MRSA and an indwelling device did not have EBP signage or a PPE cart outside their room, contrary to facility policy and physician orders. The infection preventionist confirmed that EBP should have been initiated upon admission and maintained throughout the resident's stay, with appropriate signage and supplies in place. The facility also failed to follow protocols for changing respiratory equipment, such as oxygen tubing, nebulizer sets, and yankauers, for two residents. Equipment was observed to be dated several weeks prior, indicating it had not been changed weekly as required by physician orders and facility policy. The infection preventionist confirmed that the equipment should have been changed and properly stored to prevent contamination, and that failure to do so could result in preventable infections.
Failure to Maintain Resident Privacy and Provide Safe, Dignified Personal Items
Penalty
Summary
Staff failed to maintain privacy and dignity for two residents during care and daily living activities. In one instance, a resident with severe cognitive impairment and total dependence for personal care was observed receiving incontinent care with both the privacy curtain and room door left open, exposing the resident to view by others in the hallway. The CNA involved acknowledged not closing the curtain or door, and another CNA confirmed that privacy should be maintained during such care to prevent resident embarrassment. Review of facility policy confirmed the expectation to promote privacy and dignity during care, which was not followed in this case. In a separate incident, another resident with the capacity to make decisions was found with a water pitcher that had a cracked, chipped spout with sharp edges on their bedside table. The resident confirmed the condition of the pitcher, and staff interviews indicated that such items are not acceptable due to safety and dignity concerns. Facility policy requires that residents be treated with respect and dignity, including providing a safe environment and appropriate personal items, which was not ensured for this resident.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights placed within reach, as required by policy. For one resident with a history of falls, muscle spasms, and dementia, the call light was observed on the floor behind the bed and disconnected from the wall. The resident was unable to locate the call light and requested assistance. A CNA confirmed the call light was not accessible and stated it should have been within the resident's reach. The Assistant Director of Nursing also acknowledged the importance of call lights being accessible to residents. For another resident with diagnoses including type 2 diabetes, difficulty walking, and lack of coordination, the call light was also found on the floor and not within reach. The resident required partial to moderate assistance with daily activities. A CNA confirmed the call light was not accessible and acknowledged the risk of injury if the resident attempted to retrieve it. Review of the facility's policy indicated that residents should have access to a call system to request staff assistance.
Failure to Maintain Clean Side Rail Pads for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, insomnia, and dependence on supplemental oxygen was observed in bed with their face touching padded side rails that were visibly soiled with dry, yellow, and brown food stains. The resident's Minimum Data Set indicated moderately impaired cognitive skills and total dependence on staff for eating, toileting hygiene, and personal hygiene. During the observation, both the activity aide and a CNA confirmed that the side rail pads were dirty and acknowledged that the resident's face was in contact with the soiled pads while sleeping. Further interviews revealed that the facility's Quality Assurance Nurse stated side rail pads should be disinfected daily and as needed to prevent cross contamination and ensure resident safety and comfort. A review of the facility's infection prevention and control policy confirmed the requirement to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. The failure to keep the side rail pads clean resulted in an unsanitary environment and placed the resident at potential risk for infection.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's needs by not reflecting the resident's current oxygen therapy on the Minimum Data Set (MDS). The resident, who was admitted with diagnoses including dementia, epilepsy, aphasia, and dysphagia, had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite having a physician's order for oxygen at two liters per minute via nasal cannula every shift, and documentation on the Medication Administration Record confirming daily administration of oxygen, the MDS did not indicate that the resident was receiving oxygen therapy. During interviews, the MDS nurse acknowledged that the omission was an error and stated that the resident's oxygen therapy should have been included in the MDS to accurately reflect the resident's respiratory treatment. The MDS Nurse Supervisor also confirmed the importance of the MDS as an accurate representation of the resident's assessments, care planning, treatments, and interventions. Review of facility policy indicated that the Resident Assessment Instrument (RAI) process is to be used as the basis for accurate assessment of each resident's functional capacity and health status.
Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The facility failed to develop or revise a comprehensive care plan for a resident who was prescribed Seroquel, an antipsychotic medication. The resident had multiple diagnoses, including bipolar disorder, major depressive disorder, difficulty walking, and a history of schizophrenia, as well as a diagnosis of dementia that was not reflected in the current admission record. The care plan for the use of Seroquel was not reviewed or updated to reflect the resident's current diagnoses or needs, and there was no documentation of nonpharmacological interventions to address the resident's behavioral and psychological symptoms. Interviews with facility staff and the psychiatrist revealed inconsistencies in the resident's diagnoses, with the psychiatrist unable to confirm schizophrenia and instead noting major depressive disorder and dementia as primary concerns. The facility's policy required individualized, updated care plans with specific interventions and goals for psychotropic medication use, but this was not followed. The lack of an updated care plan and nonpharmacological interventions placed the resident at risk for not receiving care tailored to their current condition and medication regimen.
Failure to Ensure Proper G-Tube Care and Infection Control
Penalty
Summary
The facility failed to provide proper care and treatment for gastrostomy tube (G-tube) management for two residents. For one resident with dementia, diabetes, and depression, the head of bed (HOB) was not elevated to the required 30 to 45 degrees during G-tube feeding, as specified in the physician's order and care plan. Observations showed the resident lying flat in bed while receiving tube feeding, and staff interviews confirmed that the HOB was not elevated as required. Facility policy also required the resident to be in a semi-Fowler's position during and after tube feeding. For another resident with dysphagia, diabetes, and anemia, the facility failed to maintain a clean valve on the G-tube. During observation, the valve was found to be dirty with black dry discoloration. Staff interviews confirmed that a dirty valve was not acceptable due to infection control concerns. It was also revealed that the facility did not have a policy or procedure in place for maintaining the cleanliness of the valve, despite having a general infection prevention and control program. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adherence to physician orders, care plans, and infection control practices led to the findings for both residents.
Failure to Ensure Complete Dialysis Access Site Assessment and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident receiving hemodialysis by not ensuring proper assessment and documentation of the resident's right upper arm arteriovenous (AV) shunt vascular access, as required by facility policy. Record reviews showed that the resident, who had end stage renal disease and was dependent on dialysis, had multiple instances where dialysis communication records from the dialysis center were incomplete. These records, covering several dates, lacked full documentation of the dialysis access site assessment, including checks for signs and symptoms of infection, and whether bruit and thrill were present. Interviews with the Assistant Directors of Nursing confirmed that the incomplete documentation could cause confusion in care delivery and that the receiving nursing staff should have contacted the dialysis center when records were incomplete. The facility's policy required regular written communication from the dialysis provider, including vital signs, pre- and post-dialysis weight, and any problems encountered, but this was not consistently documented for the resident in question.
Failure to Provide One-to-One Sitter for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not implementing a care plan intervention for a resident diagnosed with depression and suicidal ideation. The resident had a documented order and care plan for one-to-one sitter supervision following statements expressing a desire to die and refusal of medication. Despite this, on the night in question, there was no sitter present in the resident's room, as confirmed by multiple staff interviews and direct observation. Nursing notes and staff interviews indicated that the assigned staff were not aware of the sitter requirement, and the unit was short-staffed, with no additional personnel assigned to provide the required supervision. The facility's own policy required immediate one-to-one supervision for residents expressing suicidal ideation, and staff were obligated to report such statements to supervisors. However, the LVN on duty did not inform the RN supervisor about the lack of a sitter, and the Director of Staff Development could not provide documentation of staff assignment for the required supervision period. The Director of Nursing was also unaware of why the sitter was not assigned, despite the active order. This failure to implement the care plan and follow facility policy resulted in the resident not receiving the necessary behavioral health services as required.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's stated food preferences, specifically the dislike of pasta, as documented in the resident's care plan and dietary profile. Despite clear documentation that the resident did not want pasta and that the facility would honor food preferences, the resident was repeatedly served meals containing pasta or noodles, such as chicken noodle soup and a lunch tray with noodles. The resident expressed dissatisfaction with receiving these items and stated she would not eat them. Staff interviews revealed a lack of clarification regarding the resident's definition of pasta, with a CNA distinguishing between noodles and pasta, while the resident considered both to be the same. The Dietary Service Supervisor acknowledged that staff did not clarify the resident's preferences to ensure they were honored. The facility's policy required that resident preferences be reflected on tray cards and that the dietary department provide meals consistent with those preferences, but this was not followed in this case.
Failure to Accurately Document Oxygen Therapy Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not properly documenting the administration of oxygen therapy. The resident, who had diagnoses including sepsis, dysphagia, muscle weakness, and COPD, had a physician's order for oxygen at 2 liters via nasal cannula as needed. However, during multiple observations and interviews, it was found that there was no oxygen set up or available at the resident's bedside, and several nurses confirmed that oxygen was not administered during the reviewed period. Despite this, the Medication Administration Record (MAR) indicated that oxygen was administered to the resident from the 1st to the 6th of the month. Multiple licensed nurses acknowledged that they did not administer the oxygen, yet the MAR reflected otherwise, indicating inaccurate documentation by at least six licensed nurses. The facility's policy requires nursing documentation to be concise, clear, pertinent, and accurate, which was not followed in this instance.
Arbitration Agreement Lacks Required Information on Neutral Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that its arbitration agreement, as signed by a resident, included information regarding the use of a neutral arbitrator and the selection of a venue convenient to both parties, as required by federal regulations and the facility's own policy. During review, it was found that the arbitration agreement signed by a resident did not contain these provisions. The Resident Ambassador, who explained the agreement to the resident, stated that she only read what was included in the document and did not provide information about a neutral arbitrator or convenient venue, as this information was not present in the form and she was unaware it was necessary. The Admissions Director confirmed that the facility had recently adopted a shortened version of the arbitration agreement and was not aware that it needed to include language about a neutral arbitrator and convenient venue. The facility's policy indicated that the arbitration agreement should comply with federal and state laws, and that the administrator or designee is responsible for ensuring the use of the latest compliant version. This omission resulted in an incomplete understanding of the arbitration agreement for the resident involved.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two of five sampled residents by not addressing exposed electrical wiring and overflowing trash cans. For one resident with diagnoses including diabetes mellitus, anemia, hemiplegia, and hemiparesis, surveyors observed exposed wires on the bed control in the resident's room. Both a CNA and an LVN confirmed the presence of the exposed wires and acknowledged that this was unacceptable and dangerous. Another resident, with a history of hypertension, diabetes mellitus, and anemia, was found to have exposed call light wires in their room. An LVN confirmed the exposed wires and stated this placed the resident at risk for accident. Additionally, in one resident room, the trash can was observed to be open and overflowing with used PPE. A registered nurse stated that trash cans were supposed to be closed at all times, and that exposed wiring was not acceptable as it could harm residents and staff. Review of the facility's policies and procedures indicated requirements for maintaining a safe, clean, and comfortable environment, which staff acknowledged were not followed in these instances.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as required by its Abuse Prevention and Prohibition Program. One resident with severe cognitive impairment and behavioral issues, including hallucinations and a history of behavioral problems, tipped over the wheelchair of another resident who also had severe cognitive impairment and physical limitations due to Parkinson's Disease and dementia. This incident occurred while the resident was being wheeled toward the dining room, resulting in the other resident falling and hitting her head on a doorway, causing a minor skin tear and bleeding. Staff observations and interviews confirmed that the incident was witnessed by a CNA, and documentation indicated that the resident who caused the incident was not adequately monitored to prevent such behavior. The facility's policy states that all residents have the right to be free from abuse and that the facility is responsible for protecting residents from abuse by anyone. The DON acknowledged that the resident was not monitored sufficiently to prevent the incident, which resulted in physical harm to another resident.
Incorrect Low Air Loss Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to set a low air loss mattress (LALM) at the correct weight setting for a resident who was at risk for pressure ulcer development. The resident, who had diagnoses including muscle weakness, sepsis, and chronic respiratory failure, was dependent on staff for most activities of daily living and had severe cognitive impairment. According to the physician's order and facility policy, the LALM was to be set based on the resident's weight, which was documented as 82 lbs. However, during observation, the LALM was found to be set at 50 lbs, which did not match the resident's actual weight. Staff interviews and record reviews confirmed that the LALM was not set according to the resident's current weight, as required by both the physician's order and the facility's pressure ulcer prevention policy. The DON acknowledged that setting the LALM below the resident's weight could put the resident at risk for skin breakdown. The care plan for the resident indicated interventions to administer treatments as ordered and monitor for effectiveness, but the incorrect mattress setting represented a failure to follow these interventions.
Failure to Lock Bed Casters for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when staff failed to lock the casters on the bed of a resident with a known history of falls and high fall risk. The resident, who had diagnoses including type 2 diabetes mellitus, gait and mobility abnormalities, and muscle weakness, was assessed as requiring partial to moderate assistance with transfers and had experienced multiple falls since admission. During an observation, the resident was seen attempting to get out of bed by holding onto the side rail and bedside table, while the bed moved due to the casters being left unlocked. The resident expressed confusion about the bed's movement. The Assistant Director of Nursing confirmed that the bed casters were left unlocked, which allowed the bed to move and could contribute to another fall. Review of the manufacturer's manual indicated that unlocked casters could result in involuntary bed movement and potential injury. Facility policy required beds to be in the lowest position with brakes locked, but this was not followed in this instance.
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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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