Santa Fe Heights Healthcare Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Compton, California.
- Location
- 2309 N Santa Fe Ave, Compton, California 90222
- CMS Provider Number
- 555732
- Inspections on file
- 75
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 49
Citation history
Health deficiencies cited at Santa Fe Heights Healthcare Center, Llc during CMS and state inspections, most recent first.
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.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with PVD, PTSD, and major depressive disorder, who had decision-making capacity and no documented behavioral symptoms on a recent MDS, was hospitalized and later medically cleared by a GACH to return. Instead of following its usual process of obtaining and reviewing clinical documents for the DON or designee to determine if the resident’s needs could be met, the facility—through the MD and DON—denied readmission based on prior alleged aggressive behavior, without receiving or reviewing current clinical records. Staff interviews confirmed that aggressive behavior was not an accepted reason to refuse readmission, that no clinical documents were obtained, and that multiple beds, including male beds, were available. Facility policies required allowing return to an available bed and obtaining appropriate medical records prior to or upon admission, but these were not followed, leading to the resident’s unnecessary extended stay in the hospital.
A resident with PTSD, major depressive disorder, and known aggressive behavior had an IDT meeting where the team identified verbal aggression toward staff and recommended ongoing monitoring of behavioral symptoms. The existing behavioral care plan listed aggressive behavior, verbal abuse, and sudden angry outbursts but did not include any intervention to monitor these behaviors, and no corresponding orders for behavior monitoring were in place to prompt shift-by-shift documentation. Nursing staff, including an LVN and an RN, acknowledged that the care plan should have been updated and that an order for behavior monitoring was needed so licensed nurses could track behavior frequency and inform the physician, consistent with facility policies requiring ongoing assessment and revision of care plans for behavioral symptoms.
A resident with dementia, osteoporosis, prior falls, impaired balance, and lower extremity impairment was care planned as a high fall risk and placed on a Falling Star Program requiring closer monitoring, environmental precautions, and documented visual checks. Despite this, nursing notes and ADL flowsheets showed no documented monitoring or visual checks before an unwitnessed fall in the resident’s room, where no floor mat was present and the resident later reported rolling out of bed, resulting in a skin tear and an acute pelvic fracture. Staff interviews revealed that CNAs and an LVN relied on informal monitoring without documentation, some were unaware of the resident’s fall-risk status, and the required Falling Star identifier and visual observation logs were not in place, contrary to facility policies requiring monitoring and documentation of fall-prevention interventions.
A resident with PTSD, major depressive disorder, and documented decision-making capacity developed agitation, verbal aggression, and sudden angry outbursts. An SBAR and subsequent care plans identified these behavioral symptoms and included an intervention for a psychological evaluation, and the IDT recommended a referral to psychology. However, no referral was made, no psychology note was found in the chart, and the consulting psychologist reported not being informed of the behavioral change. Staff stated that without the recommended psychological evaluation, the resident was at risk for psychological distress, poor coping skills, and continuation of aggressive behavior.
Licensed nursing staff administered psychotropic medications to a resident with cognitive impairment and mental health diagnoses before obtaining the required informed consent, as confirmed by record review and staff interview. The facility's policy required written informed consent prior to starting such medications, but the consent was obtained only after the medications had already been given.
Licensed nursing staff did not update the fall care plan for a resident with cognitive impairment and psychiatric diagnoses after multiple falls. Despite repeated incidents, no new interventions were developed, and staff interviews confirmed that care plans were not revised as required by facility policy, leaving the resident without effective fall prevention measures.
A resident with multiple comorbidities experienced a fall and subsequently developed new shoulder pain and limited mobility, which was observed by CNAs but not effectively communicated to the LVN or documented using the required Stop and Watch form. An LVN later noted skin redness but did not document or report it. These failures led to a delay in physician notification and the discovery of a clavicle fracture and significant bruising several days after the fall.
A resident with multiple neurological and cognitive impairments suffered an unwitnessed fall and was initially assessed by an LVN, who documented a head hematoma. Facility policy required the RN supervisor to complete the post-fall incident report and conduct a thorough assessment, but this was not done. The RN supervisor was unaware of the policy and did not perform the required assessment, resulting in a missed clavicle fracture that was only identified seven days later after the resident reported shoulder pain.
A resident with a history of schizophrenia and mood disorder exhibited ongoing erratic mood swings, auditory hallucinations, and aggressive behaviors that were not adequately monitored or addressed by staff. The facility failed to implement its abuse prevention policy, did not develop a care plan for schizophrenia, and did not document interventions for the resident's behaviors. This led to the resident physically assaulting another resident, resulting in injury and emotional distress.
A resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment, who had a history of elopement, was able to leave the facility unsupervised after removing her wander guard bracelet. The care plan required frequent visual checks but did not specify intervals or documentation, leading to unclear supervision practices. Staff interviews confirmed the lack of clarity in monitoring procedures, which contributed to the resident's unsupervised departure.
A resident with a history of hypertensive heart disease and other conditions received antihypertensive medications without required assessment or documentation of blood pressure and pulse prior to administration, as ordered by the physician and indicated in the care plan. The failure occurred due to an LVN not entering supplemental documentation fields in the eMAR, resulting in no recorded vital signs before medication administration on several occasions.
The facility failed to ensure staff were knowledgeable about the policy for storing food brought by visitors, risking bacterial growth and cross-contamination for 88 residents. Interviews revealed staff confusion about food storage procedures, with some unaware of designated storage areas and policy details. The Dietary Supervisor and LVNs showed limited understanding, while the QA Nurse stressed the importance of policy awareness for food safety.
The facility failed to ensure proper infection control practices, as a housekeeper did not perform hand hygiene after cleaning a resident's room, and a nurse did not sanitize a contaminated surface. Additionally, a resident's nebulizer equipment was improperly stored on the floor, increasing the risk of infection.
The facility failed to ensure proper storage and labeling of medications, including storing a food item with medications, not removing expired medications, and using an unapproved container for G-tube flushes. Additionally, several medications were either expired, improperly stored, or lacked proper labeling, affecting multiple residents. Controlled medications for discharged residents or discontinued orders were not removed or documented properly, posing risks of misuse.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency in food safety procedures, particularly in operating dishwashing equipment and using sanitizing solutions. Dietary Aides were unable to correctly state the acceptable temperature and chlorine concentration for the dishmachine, and the facility's competency checklists did not include verification for these tasks. Additionally, staff did not follow manufacturer's guidelines for testing QUAT sanitizer concentration, posing a risk of unsanitized dishes and potential foodborne illnesses for 87 medically compromised residents.
The facility failed to serve correct portion sizes to residents, with 75 residents on a regular diet receiving 1/3 cup instead of 1/2 cup of sweet corn salad, and four residents on a renal diet receiving less wheat pasta due to incorrect utensil use. This could lead to inadequate nutrition and unintended weight loss.
The facility failed to maintain food quality and temperature, serving sweet corn salad at 62°F and overcooked, unseasoned broccoli. Two residents, including one with malnutrition, expressed dissatisfaction with the food's taste and appearance. The Dietary Supervisor and RD acknowledged the issues, noting improper handling and serving of meals, potentially affecting residents' nutritional intake.
The facility failed to prepare pureed foods to IDDSI Level 4 standards, as observed with the pureed Cajun country rice, which was sticky and did not hold its shape. The Dietary Supervisor confirmed the inconsistency, and the Registered Dietitian noted that IDDSI diets were not implemented due to lack of training. This affected 8 residents on a pureed diet, posing risks of swallowing difficulties and unintended weight loss.
The facility exhibited multiple deficiencies in food safety and sanitation, including unclean kitchen equipment, improper storage of wet pans and dented cans, and inadequate handwashing by staff. Equipment was not maintained in a condition that prevents bacterial growth, with chipped can openers, cracked trays, and rusted scoop storage. Additionally, the freezer lacked a thermometer for temperature monitoring, and the emergency water storage area was not properly maintained.
The facility failed to honor the rights and dignity of two residents. A CNA was observed watching TV on her phone while feeding a resident, compromising safety and dignity. Additionally, the facility did not hold bioethics committee meetings or obtain public guardians for residents unable to make medical decisions, leading to the administration of psychotropic medications without proper consent.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident, with schizoaffective disorder, was given haloperidol without consent, despite lacking decision-making capacity. Another resident, with schizophrenia and severe cognitive impairment, had incomplete consent documentation for Risperdal and incorrect consent for haloperidol. The facility did not follow its policies requiring consent from a representative or bioethics committee involvement.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with multiple health issues was observed with the call light out of reach, despite care plans emphasizing its importance for fall prevention. Another resident with severe cognitive impairment also had an inaccessible call light. Staff interviews confirmed the importance of call light accessibility, but observations showed non-compliance with facility policies.
A resident with epilepsy had subtherapeutic phenobarbital levels, but the facility failed to notify the physician, contrary to policy. The resident later experienced seizures, requiring emergency intervention. The RN and DON confirmed the oversight, which was against the facility's policy to report such lab results.
A facility failed to accurately code a resident's MDS regarding their dental status, resulting in incorrect data being sent to CMS. The resident, who had dentures, was incorrectly assessed as having no oral issues. This discrepancy was confirmed by the MDS Nurse, highlighting a deficiency in the facility's assessment process.
A facility failed to accurately complete the PASARR Level I screening for a resident, omitting diagnoses of depression and anxiety. The resident's Face Sheet and MDS indicated these active diagnoses, but the PASARR incorrectly stated no serious mental illness. The DON confirmed the error, highlighting the risk of the resident not receiving necessary specialized care.
The facility failed to develop and implement comprehensive care plans for three residents, affecting their health and safety. A resident with COPD and depression lacked a care plan for dentures, another with epilepsy did not have their low Phenobarbital levels reported to a physician, leading to seizures, and a third resident on supplemental oxygen had no care plan for oxygen administration. These deficiencies highlight lapses in care planning and communication among staff.
A resident with dementia and other health issues was found with long, dirty fingernails, indicating a failure by the facility to maintain personal hygiene. Despite facility policies requiring daily cleaning and regular trimming of fingernails, observations and staff interviews revealed that these practices were not followed, potentially risking the resident's health.
A resident with severe bilateral hand contractures did not receive the ordered application of hand splints for four to five hours daily, five days a week. The RNA responsible admitted to not having enough time to complete the task, leading to inaccurate charting. The resident reported pain and occasional bleeding, and the importance of splints in preventing worsening contractures was confirmed by a COTA.
The facility failed to ensure a safe environment for residents by not following fall prevention policies, leaving a leaking sink unrepaired, and allowing a CNA to be inattentive while feeding a resident. A resident's call light was out of reach, and obstacles were present in the room, increasing fall risk. Another resident's bathroom had a leaking sink, creating a slip hazard. Additionally, a CNA watched TV on a personal device while feeding a resident with dysphagia, risking unnoticed choking.
A resident receiving oxygen therapy at two liters per minute via nasal cannula did not have the required oxygen signage outside their room or in the room, as observed and confirmed by staff. The facility's policy mandates such signage for safety, but it was not in place, despite the resident's multiple diagnoses necessitating oxygen therapy.
The facility failed to administer medications correctly for three residents, leading to potential adverse effects. A resident with atherosclerosis swallowed an aspirin chewable tablet without chewing, increasing the risk of ineffectiveness. Another resident with schizophrenia received an incorrect quetiapine dose due to discrepancies between the medication card and eMAR. Additionally, a resident's polyethylene glycol order lacked a specified frequency, risking inappropriate administration. The DON acknowledged these issues, emphasizing the need for clear dosing frequencies and resolving discrepancies.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. One resident was not instructed to chew an aspirin tablet, and another received an incorrect dose of quetiapine due to a discrepancy between the medication card and eMAR. The errors were acknowledged by the LVNs involved, and the Director of Nursing confirmed the need for accurate medication administration.
A resident with cognitive impairments was verbally and physically abused by another resident over a dispute about snacks. The incident involved yelling and throwing water, violating the facility's policy on maintaining an abuse-free environment.
The facility failed to report an incident of resident-to-resident verbal and physical abuse within the required timeframe. A resident with severe cognitive impairment reported being verbally abused and having water thrown at him by his roommate, who admitted to the altercation. The incident was not reported to the DON, Administrator, or CDPH as required, delaying an investigation and potentially placing all residents at risk. Facility policies on abuse reporting were not followed.
A facility failed to investigate a resident-to-resident abuse incident involving two residents, one with severe cognitive impairment and the other with intact cognitive skills. The incident involved verbal abuse and physical aggression over a dispute about snacks. The DON acknowledged the failure to investigate promptly, and an LVN witnessed but did not report the incident immediately, contrary to the facility's policy.
The facility did not meet the required 80 square feet of room space per resident for 22 rooms, as identified in a Room Waiver Request. Despite this, the Administrator stated that resident care was minimally impacted and that necessary medical equipment could still be accommodated. Observations during the survey did not show adverse effects on residents' care or safety.
A facility failed to notify a physician about a resident's wandering behaviors and did not conduct an IDT meeting to assess the resident's risk for wandering. The resident, diagnosed with dementia, exhibited wandering on multiple occasions, but the LVN did not inform the physician. The facility's policies require notifying the physician of significant changes and conducting IDT assessments, which were not followed.
A resident with a history of aggressive behavior was not sent for psychiatric evaluation as ordered by a physician, leading to unprovoked physical abuse incidents involving two other residents. The facility failed to document and act on the physician's order, resulting in repeated aggression and injuries.
A resident with dementia and severe cognitive impairment wandered into another resident's room, resulting in a physical altercation. Despite known wandering behaviors, no care plan was initiated to address this issue, as confirmed by an LVN. The facility's policies required comprehensive care plans and safety interventions, which were not implemented, leading to the incident.
Two residents in an LTC facility were subjected to physical abuse due to inadequate supervision and failure to manage known behavioral issues. One resident with severe cognitive impairment struck another, causing a nasal fracture, while another resident slapped a peer when left unsupervised. The facility's abuse prevention policy was not effectively implemented, leading to these incidents.
The facility failed to document resident altercations and necessary care interventions for several residents with complex medical and psychiatric conditions. Incidents of resident-to-resident altercations were not recorded, and required monitoring and interventions were missing from MARs. The lack of documentation could lead to missed changes in residents' conditions and delay necessary care.
A resident on 1:1 supervision slapped another resident after being left unsupervised by an Activities Aide who needed to inform the charge nurse of her departure. The resident had a history of behavioral issues, including sudden angry outbursts. The facility's policy required constant supervision, which was not followed, leading to the incident.
A resident experienced a significant decline in oxygen saturation levels, and the facility failed to notify the physician in a timely manner, resulting in delayed hospital transfer. The resident also refused neurological and skin assessments, but the facility did not inform the physician, risking undetected complications. The facility's inaction led to inadequate monitoring of the resident's condition.
A resident with severe cognitive impairment and multiple health issues refused skin check assessments during ADLs, yet the facility failed to revise the care plan to address this ongoing issue. Despite the resident's independence and refusal of assistance, the care plan was not updated to guide staff in managing the resident's skin integrity, as required by facility policy.
A resident with severe cognitive impairment and multiple venous ulcers did not receive ordered wound care treatments on two occasions. The facility's Treatment Nurse and other licensed nurses failed to administer the necessary care, as indicated by empty boxes on the Treatment Administration Record. The facility's policy emphasized the importance of following physician orders and documenting care, which was not adhered to in this case.
Two residents experienced falls that were not properly reported or assessed in a timely manner. One resident was moved by CNAs before a nurse could assess them, leading to a delay in necessary medical evaluations. Another resident refused neurological assessments, which were not conducted according to the required schedule. These actions violated facility procedures and compromised resident safety.
A facility failed to ensure a psychiatry note was available in a resident's chart, potentially affecting care. The resident, with schizophrenia and bipolar disorder, had severe cognitive impairment. Despite an order for psychiatric evaluation, no notes were found. Interviews revealed that notes are usually emailed and printed for charts, but this was missed, raising concerns about care continuity.
A resident with schizoaffective disorder and a history of behavioral symptoms, including auditory hallucinations and yelling at staff, was not accurately coded for these behaviors on the MDS assessment. The MDS nurse failed to document the behaviors in section E, resulting in incorrect data being sent to CMS.
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.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Follow Readmission Process and Improper Denial of Return from Hospital
Penalty
Summary
The deficiency involves the facility’s failure to follow its established readmission process for a hospitalized resident who had been medically cleared to return from a general acute care hospital (GACH). The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and had been initially admitted and later readmitted to the facility prior to the hospitalization. An MDS dated 1/5/2026 documented modified independence in cognitive skills for daily decision making, no physical or verbal behavioral symptoms directed toward others, and a need for moderate assistance with toileting, dressing, and personal hygiene. The resident was discharged to the GACH with return anticipated, and a prior H&P indicated the resident had capacity to understand and make decisions. When the GACH determined the resident was medically cleared for discharge back to the facility, the GACH case manager reported that the facility refused readmission before receiving any clinical documents. The case manager stated that clinical documents were not sent because the facility declined the readmission and that the facility cited aggressive behaviors as the reason, despite the resident being calm and exhibiting appropriate behavior at that time. Facility staff, including RN 1 and the Marketing Director (MD), described the usual readmission process as beginning with a phone call from the GACH followed by transmission of clinical documents for review by the DON or designee to determine whether the resident’s needs could be met, including any special treatments or isolation requirements. RN 1 stated there were few valid reasons to decline readmission, such as lack of available beds or required services not provided by the facility, and that aggressive behavior was never an acceptable reason. In this case, the receptionist reported receiving a call from the GACH about the resident’s potential readmission and transferring it to the MD, who was temporarily handling admissions. The MD acknowledged informing the GACH case manager that the facility would not accept the resident back due to behavior, referencing prior screaming at staff and a possible incident of hitting a staff member, and stated that the DON made the decision to deny readmission based on this past behavior. RN 1 confirmed that the facility had no clinical documents to review for this readmission and that the denial was made without such review. A census review for the date of the attempted return showed 11 empty beds, including six available for a male resident, indicating the facility could have accommodated the resident. Facility policies on bed-holds and admission criteria required that residents be permitted to return to an available bed and that appropriate medical records be received prior to or upon admission, which were not followed, resulting in the resident’s denial of return and an unnecessary nine-day stay at the GACH.
Failure to Revise Care Plan and Orders to Monitor Aggressive Behavior
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include monitoring of aggressive behavior as recommended by the Interdisciplinary Team (IDT). The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was assessed as having modified independence in cognitive skills for daily decision making, with moderate assistance needed for several ADLs. The resident’s history and physical indicated capacity to understand and make decisions. An SBAR dated 11/27/2025 documented that the resident exhibited behavioral symptoms such as agitation when frustrated and when he believed he was being targeted by staff. On 11/28/2025, the IDT met with the resident to address issues related to his verbal aggression toward staff. The IDT Conference Record documented that the team discussed his behavior of verbal aggression and recommended interventions for the plan of care that included continuing to monitor his behavior. However, the resident’s care plan for behavioral symptoms, dated the same day, listed manifestations such as aggressive behavior, verbal abuse, and sudden angry outbursts, but did not include any intervention to monitor these behaviors. LVN 1 confirmed during interview and concurrent record review that the care plan should have been revised to reflect the IDT’s recommendation to monitor the resident’s behavior. Further review of the resident’s active orders on 2/3/2026 showed no orders to monitor for aggressive behavior, verbal abuse, or sudden angry outbursts. LVN 1 stated that a behavior monitoring order would have prompted licensed nurses to document the frequency of behaviors every shift to gather information and determine changes in frequency for physician notification. RN 1 stated that the resident was known to have aggressive behavior and had a 1:1 sitter for safety, and that the IDT’s recommendation to monitor behavior should have been communicated to the physician to obtain an order for every-shift monitoring. RN 1 also stated that the IDT was responsible for updating the care plan so licensed nurses would be aware of the need to monitor and document the frequency of the resident’s aggressive behavior. Facility policies on comprehensive care plans and behavioral assessment indicated that care plans are to be revised as resident information and condition change, and that the IDT evaluates behavioral symptoms and develops a plan of care accordingly.
Failure to Implement and Document Fall Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document fall risk interventions, including visual checks and monitoring, for a resident identified as a fall risk, which resulted in an unwitnessed fall. The resident had diagnoses including age-related osteoporosis with pathological fracture, history of falling, dementia, and osteoarthritis of both hips. An H&P noted the resident had capacity to understand and make decisions, while an MDS assessment documented severely impaired cognitive skills for daily decision-making, bilateral lower extremity impairment, and the need for assistance with transfers and ambulation, with wheelchair use for mobility. Multiple care plans identified the resident as at risk for falls due to history of falls, hypoxia, impaired balance, and brain injury, with goals for the resident to remain free of falls and interventions including placement on the Falling Star (Yellow Star) Program and initiation of fall risk precautions. Care plans and the facility’s fall prevention program required monitoring and documentation of fall risk interventions, including closer monitoring, frequent rounds, and visual checks for residents on fall precautions. The Falling Star Program used a yellow star outside the resident’s room to identify fall risk and called for the bed to be in the lowest position and floor mats on both sides of the bed. The Quality Assurance Nurse stated that residents on fall precautions were to be monitored closely by CNAs, with documentation of monitoring on ADL task flowsheets, and that visual checks required hourly documentation on a Visual Observation Log posted in the resident’s room. However, review of nursing progress notes from 1/20/2026 through 1/23/2026 and the ADL documentation for January 2026 showed no documented monitoring or visual checks for the resident prior to the fall, with the last CNA entry recorded the night before the fall. The QAN acknowledged that in the absence of documentation, there was no way to determine whether fall risk monitoring or interventions were implemented. On the date of the incident, a Change in Condition evaluation documented that the resident was found on her right side on the floor, with a skin tear to the right upper extremity, and the resident stated, "I rolled out of bed." A Post Fall Evaluation recorded that the unwitnessed fall occurred in the resident’s room when the resident rolled out of bed, and that no floor mat was present at the time of the fall. Subsequent nursing documentation noted an acute right pelvic fracture and transfer to a general acute care hospital for further evaluation and treatment. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA reported making 20–30 minute rounds and visual checks on fall-risk residents but not documenting this, another CNA described the resident’s repeated attempts to get out of bed and into a wheelchair, and a nurse stated she did not know the resident was a fall risk and therefore did not implement increased visual checks. Observations after the fall showed the resident attempting to get out of bed, with low bed and floor mats in place, but without a Falling Star symbol posted outside the room, despite the resident being on the Falling Star Program. Facility policies on charting, falls and fall risk management, and assessing falls required staff to monitor, evaluate, and document interventions and resident responses, which were not carried out or documented as required for this resident.
Failure to Arrange Psychology Consult After Onset of Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to arrange a psychology consult for a resident after the onset of aggressive behavioral symptoms, despite multiple assessments and care plans indicating the need for such an evaluation. The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was documented as having the capacity to understand and make decisions. An MDS assessment showed modified independence in cognitive skills for daily decision-making and a need for moderate assistance with toileting, dressing, and personal hygiene. On 11/27/2025, an SBAR documented that the resident exhibited behavioral symptoms, including agitation when frustrated and a belief that he was being targeted by staff. Following this change in condition, the resident’s care plans titled “Aggressive Outbursts” and “Behavioral Symptoms,” dated 11/27/2025 and 11/28/2025 respectively, identified aggressive behavior, verbal abuse, and sudden angry outbursts, and specifically included interventions for a psychological evaluation. An IDT conference record dated 11/28/2025 showed that the team met with the resident to discuss verbal aggression toward staff and recommended a referral to psychology for a consultation. Despite these documented recommendations and care plan interventions, interviews and record review revealed that no psychology evaluation was completed and no psychology note was found in the resident’s medical record after the behavioral change on 11/27/2025. The SSD stated that when the IDT recommended a psychology referral, the referral should be made so the psychologist could evaluate the resident as soon as possible after behavioral symptoms. The psychologist reported he did not recall being informed of the resident’s behavioral change and stated he had not been made aware of the need for an evaluation. Facility staff, including the SSD and RN 1, stated that psychological evaluations were important for residents to express feelings, identify root causes of behavior, and develop coping skills, and that without the recommended evaluation the resident was at risk for psychological distress, poor coping skills, and continuation of aggressive behavior. The facility’s behavioral health policy and the Social Services Designee job description indicated that the facility was responsible for providing behavioral health services as needed and coordinating with outside psychology professionals, which did not occur in this case.
Psychotropic Medications Administered Without Prior Informed Consent
Penalty
Summary
Licensed nursing staff failed to obtain informed consent prior to administering psychotropic medications to a resident diagnosed with paranoid schizophrenia and bipolar disorder. The resident, who had fluctuating capacity to understand and make decisions and was assessed as moderately impaired in cognitive skills, was admitted with orders for multiple psychotropic medications, including quetiapine fumarate, valproic acid, and olanzapine. According to the Medication Administration Report, these medications were administered starting on 7/17/2025. However, the Verification of Informed Consent form for these medications was not completed until 7/22/2025, indicating that the resident received psychotropic medications for several days before consent was obtained. Interviews with a registered nurse confirmed that the medications were given prior to obtaining the required informed consent, which was contrary to the facility's policy and procedure mandating written informed consent before initiating psychoactive medication use.
Failure to Revise Fall Care Plan After Multiple Resident Falls
Penalty
Summary
Licensed nursing staff failed to revise the fall care plan for a resident after multiple falls, as evidenced by record reviews and staff interviews. The resident, who was admitted with diagnoses including paranoid schizophrenia and bipolar disorder, had fluctuating capacity to understand and make decisions, and required supervision for activities of daily living due to moderately impaired cognitive skills. Despite documented falls on several occasions, the care plan interventions were not updated after each incident, and no new interventions were developed to address the recurring falls. Interviews with nursing staff confirmed that care plans should be revised after every fall, and that the lack of updated interventions meant there were no additional measures in place to minimize future falls. The facility's policy required staff to implement additional or different interventions if falls reoccurred, or to justify the continuation of current interventions, but this was not followed. As a result, the resident did not have effective interventions in place to minimize future falls and injuries.
Failure to Communicate and Document Change in Condition After Resident Fall
Penalty
Summary
The facility failed to identify, document, and communicate changes in condition for a resident following an unwitnessed fall. Certified Nursing Assistants (CNAs) observed new onset of shoulder pain and limited range of motion in the resident while assisting with dressing on two separate occasions, but did not effectively communicate these changes to the Licensed Vocational Nurse (LVN) and did not complete the required Stop and Watch form, which is the facility's designated CNA-to-LVN communication tool. Additionally, one CNA stated she verbally notified the LVN but did not document the change, while another CNA admitted to forgetting to complete the form. The LVNs involved reported not being made aware of the resident's pain or range of motion limitations, and as a result, did not perform further assessments or notify the physician for further evaluation. On a separate occasion, an LVN noted new skin redness to the resident's right shoulder three days after the fall but failed to document the finding, assess for range of motion changes, or notify the physician or RN Supervisor. The LVN stated that the omission was due to being busy with medication administration. The lack of documentation and communication meant that other licensed nurses and the physician were not made aware of the resident's new symptoms, and no change of condition note was initiated. Interviews with other staff confirmed that the facility's policy required such findings to be documented and communicated promptly, especially following a fall. The resident involved had a history of falling, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, and required moderate assistance with activities of daily living. The resident's care plan specified that nurses were to call the physician for any significant change of condition and assess for nonverbal signs and symptoms of pain. Despite these requirements, the new onset of pain and functional decline was not effectively communicated or documented, resulting in a delay in physician notification and the discovery of a clavicle fracture and significant bruising several days after the initial fall.
Failure of RN Supervisor to Complete Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) supervisor completed the post-fall incident report and assessment as required by facility policy for a resident who experienced an unwitnessed fall. The resident, who had a history of falls, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, was found lying in the hallway and reported a fall. An initial assessment by an LVN documented a hematoma on the back of the resident's head, and the physician was notified, resulting in an order for a skull x-ray. Despite facility policy stating that the RN supervisor on duty must complete the Fall Incident Report within 24 hours and conduct a thorough post-fall assessment, the report was completed by the LVN instead. The RN supervisor, who was on lunch break at the time of the fall, did not conduct the required assessment or complete the incident report, stating he was unaware of the policy. The Director of Nursing confirmed that the RN supervisor was responsible for conducting a comprehensive assessment, even if an LVN had already performed an initial evaluation. Seven days after the fall, the resident complained of right shoulder pain and discoloration, leading to an x-ray that revealed a displaced, acute comminuted fracture of the right clavicle. The facility's Quality Assurance Nurse acknowledged that adherence to policy would have prompted an RN-level assessment, which could have identified injuries not detected during the LVN's assessment.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically attacked another. A resident with diagnoses including schizophrenia, mood disorder, and other medical conditions exhibited erratic mood swings, auditory hallucinations, and aggressive behaviors over several days. Despite these behaviors being documented in the Medication Administration Record (MAR), there was no detailed description of the behaviors or documentation of staff interventions. The facility did not implement its own Abuse Prevention/Prohibition policy, which required understanding and monitoring behavioral symptoms that could increase the risk of abuse, such as aggression and outbursts. There was no individualized care plan addressing the resident's schizophrenia, nor were interventions developed to monitor and re-evaluate the effectiveness of behavioral management strategies. The existing care plans for psychosocial well-being and mood patterns were not followed, as there was no documentation that staff listened attentively or addressed the resident's concerns during periods of erratic mood swings and hallucinations. Staff interviews revealed that aggressive and disruptive behaviors were observed but not consistently reported or documented, and there was a lack of communication among staff regarding these behaviors. As a result of these failures, the resident with schizophrenia physically assaulted another resident, causing visible injury, pain, and emotional distress. The assaulted resident expressed feeling unsafe and fearful of being alone, and required pain medication for the injuries sustained. The incident was witnessed by staff, and subsequent interviews confirmed that the aggressive behaviors had been ongoing and inadequately managed, with insufficient documentation and monitoring to prevent harm.
Failure to Provide Adequate Supervision for High-Risk Elopement Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident identified as high risk for elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and anxiety disorder, was assessed as having moderate cognitive impairment and required partial to moderate assistance with activities of daily living. The resident had a documented history of elopement attempts and had verbally expressed a desire to leave the facility. Despite these risk factors, the resident was able to remove her wander guard bracelet, which she found uncomfortable, and refused to have it reapplied. The care plan was updated to indicate frequent visual checks, but did not specify the frequency or documentation requirements for these checks. On the day of the incident, the resident was able to leave the facility without staff knowledge by using a chair to exit through a window. She spent the day shopping and returned to the facility without injury, only informing her sister of her whereabouts. Interviews with staff revealed that the care plan's instructions for frequent visual checks were unclear, lacking specific intervals and documentation protocols. Both the LVN and DON acknowledged that the care plan should have been more precise to ensure the resident's safety and adequate supervision. A review of facility policies indicated that individualized care plans should include measurable objectives and timetables, and that resident safety and supervision are facility-wide priorities. However, the lack of specificity in the resident's care plan and the absence of clear monitoring procedures contributed to the failure to prevent the resident's elopement.
Failure to Assess and Document Vital Signs Prior to Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure and pulse were assessed and documented prior to the administration of hydralazine and lisinopril, as required by physician orders and the resident's care plan. The resident, who had diagnoses including hypertensive heart disease, chronic pulmonary edema, and schizophrenia, was admitted with specific medication orders that required holding the blood pressure medications if the systolic blood pressure was less than 110 mm Hg or the pulse was less than 60 beats per minute. Despite these clear parameters, the electronic medication administration record (eMAR) and vital signs summary showed no documentation of blood pressure or pulse measurements prior to medication administration on multiple occasions. Interviews with the DON and an LVN revealed that the lack of documentation was due to the LVN's failure to input the necessary supplemental documentation fields in the eMAR, which prevented nurses from recording the required vital signs before administering the medications. As a result, there was no evidence that the resident's vital signs were checked as ordered, and the medications were administered without the necessary assessments. Facility policies and job descriptions reviewed indicated that comprehensive care planning and proper medication administration and documentation were required, but these were not followed in this instance.
Staff Unfamiliarity with Food Storage Policy Poses Risk
Penalty
Summary
The facility failed to ensure that staff were knowledgeable about the policy regarding the use and storage of food brought to residents by family and other visitors. This deficiency was identified through observations, interviews, and record reviews, revealing that two staff members were unable to verbalize the policy. The policy, titled 'Food for Residents from Outside Sources,' outlines procedures for monitoring and storing non-perishable and perishable foods to ensure safe and sanitary conditions. However, staff interviews indicated a lack of familiarity with these procedures, which could potentially lead to harmful bacterial growth and cross-contamination, posing a risk of foodborne illness to the 88 medically compromised residents who store food in the facility's refrigerators. Interviews with various staff members, including the Dietary Supervisor, Licensed Vocational Nurses, and the Quality Assurance Nurse, highlighted inconsistencies in understanding and implementing the policy. The Dietary Supervisor mentioned that the facility did not have a designated refrigerator for residents' food in the kitchen, and the responsibility for maintaining the resident's refrigerator was unclear. Licensed Vocational Nurses expressed limited knowledge of the policy, with one nurse incorrectly stating that food could not be stored in the kitchen. The Quality Assurance Nurse, responsible for monitoring food safety, emphasized the importance of staff awareness of the policy to prevent food spoilage and bacterial growth. These findings indicate a gap in staff training and communication regarding the facility's food storage policy.
Infection Control Deficiencies in Housekeeping and Nursing Practices
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by housekeeping and nursing staff. During an observation, a housekeeper was seen collecting trash from a resident's room with gloved hands, removing the gloves, and then exiting the room without performing hand hygiene. The housekeeper then touched another trash can lid in the hallway without washing her hands. In an interview, the housekeeper acknowledged the importance of handwashing to prevent the spread of infection but admitted to forgetting on this occasion. Additionally, a nurse failed to sanitize a high-traffic surface area contaminated with body fluids. An observation noted a resident with mucus dripping from his nose, which landed on the nursing station counter. The nurse placed a paper towel over the mucus, handed it to the resident, and walked away without disinfecting the counter or washing her hands. The nurse later admitted that she should have disinfected the counter and washed her hands to prevent potential exposure to other residents and visitors. Furthermore, the facility did not ensure that a resident's nebulizer equipment was stored properly. The nebulizer machine, mask, and tubing were observed on the floor, with the tubing undated. The resident, who had chronic obstructive pulmonary disease, required the nebulizer for medication administration. The nurse confirmed that the equipment should have been placed on a table, dated, and stored in a plastic bag to prevent contamination and reduce the risk of respiratory infection.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during an inspection of the Station A Medication Room and Medication Carts. A bottle of Sriracha sauce was found stored alongside medications, posing a risk of cross-contamination. Additionally, expired niacin tablets were not removed from the medication stock, which could lead to ineffective or unsafe administration. An unapproved container was also used for measuring water for G-tube flushes, which was not in accordance with facility standards. Further deficiencies were noted in the storage and labeling of various medications, including vitamin B12, latanoprost ophthalmic solution, insulin glargine, metoclopramide oral solution, cranberry tablets, and vitamin D3 tablets. These medications were either expired, not stored according to manufacturer requirements, or lacked proper labeling, such as open dates. This affected several residents, including those with conditions requiring specific medication regimens, such as glaucoma and diabetes, potentially compromising their treatment. The facility also failed to manage controlled medications properly. Fifteen controlled medications for discharged residents or discontinued orders were not removed from the medication cart and were not documented daily in the controlled medication accountability record. This oversight involved medications such as clonazepam, lorazepam, temazepam, hydrocodone-acetaminophen, zolpidem, tramadol, and diphenoxylate-atropine, affecting multiple residents. The facility's Director of Nursing acknowledged the lapses in medication management and the potential risks associated with these deficiencies.
Inadequate Training and Competency in Kitchen Sanitation Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in handling food safety procedures, specifically regarding the operation of dishwashing equipment and the use of sanitizing solutions. During observations and interviews, it was found that Dietary Aides were unable to correctly verbalize the acceptable temperature for the low-temperature dishmachine and the correct chlorine concentration range. This lack of knowledge was evident when Dietary Aide 1 incorrectly stated the temperature range and was unsure of the chlorine concentration range, while Dietary Aide 2 initially provided incorrect information and later admitted to not knowing the acceptable chlorine concentration range. Further investigation revealed that the facility's policies and procedures were not being followed. The facility's policy indicated that the low-temperature dishmachine should operate at a range of 120 F to 140 F, with a chlorine concentration of 50-100 ppm. However, the Dietary Aides were not adhering to these guidelines, as evidenced by their inability to accurately determine the concentration of the sanitizing solution using test strips. Additionally, the facility's competency checklists for the Dietary Aides did not include verification for dishmachine temperatures or sanitizer concentration checks, indicating a gap in training and competency evaluation. The facility also failed to ensure proper use of quaternary ammonium compound (QUAT) sanitizer. Observations showed that staff were not following the manufacturer's guidelines for testing the QUAT sanitizer concentration, which should be between 150-400 ppm at a minimum temperature of 75 F. Instead, the facility's log indicated a testing temperature range of 69-71 F, which did not align with the manufacturer's instructions. This discrepancy in following proper procedures for sanitizing solutions posed a risk of unsanitized dishes, potentially leading to foodborne illnesses among the 87 medically compromised residents who received food and ice from the kitchen.
Incorrect Portion Sizes Served to Residents
Penalty
Summary
The facility failed to adhere to its menu guidelines, resulting in incorrect portion sizes being served to residents. Specifically, 75 out of 88 residents on a regular texture diet received only 1/3 cup of sweet corn salad instead of the prescribed 1/2 cup. This discrepancy was due to the use of an incorrect scoop size by a staff member, who misread the menu spreadsheet. The Dietary Supervisor confirmed the error and acknowledged that using a smaller scoop could lead to residents not receiving adequate nutrition, potentially resulting in unintended weight loss. The facility's recipe and policy documents also indicated the correct portion size should have been 1/2 cup. Additionally, four out of six residents on a renal diet were served less than the required portion of wheat pasta with margarine because a regular serving spoon was used instead of the specified spoodle. The Dietary Supervisor noted that the use of incorrect utensils could result in residents receiving fewer calories than needed, which could negatively impact their nutritional status. The Registered Dietitian emphasized the importance of using the correct scoops and utensils to ensure proper portion sizes are served, as outlined in the facility's policies and procedures.
Deficiencies in Food Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Observations revealed that the sweet corn salad was served at 62 degrees Fahrenheit, which is above the recommended temperature for cold foods, and the lettuce was wilted. Additionally, the broccoli was overcooked, mushy, and lacked seasoning, affecting its flavor and appearance. These deficiencies were observed during meal service on two consecutive days, impacting a significant number of residents, including those at risk of unplanned weight loss. Resident 34, who has a history of polyneuropathy, COPD, unspecified protein-calorie malnutrition, and chronic kidney disease, expressed dissatisfaction with the food, stating it did not taste or look good. Resident 70, with diagnoses including acute pyelonephritis, unspecified protein-calorie malnutrition, and COPD, also reported that the food was unappealing in taste and appearance. Both residents were on regular diets, with Resident 70 requiring a fortified diet. The facility's failure to maintain proper food quality and temperature potentially affected the nutritional intake of these residents. The facility's policies and procedures for meal service and food preparation were not adhered to, as evidenced by the improper handling and serving of cold and hot foods. The Dietary Supervisor and Registered Dietitian acknowledged the issues with food temperature and preparation, noting that the corn salad was improperly stored and served, and the broccoli was overcooked and unseasoned. These lapses in food service could lead to decreased meal intake and potential weight loss among residents, as the food did not meet the standards for flavor, appearance, and temperature as outlined in the facility's guidelines.
Failure to Prepare Pureed Foods to IDDSI Standards
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a pureed diet, specifically those requiring IDDSI Level 4 consistency. During an observation, the pureed Cajun country rice was found to be sticky, did not pass the spoon tilt test, and failed to hold its shape on the plate. This inconsistency was noted during a trayline observation and confirmed by the Dietary Supervisor, who acknowledged that the pureed diet should have a pudding-like consistency, be smooth, and able to hold its shape. The facility's recipe for pureed starches indicated that the finished product should be smooth, free of lumps, and meet IDDSI Level 4 testing requirements, which the rice did not. The Registered Dietitian revealed that the IDDSI diets had not been implemented, and the Dietary Supervisor had not attended the necessary training. The facility's policies and procedures required the use of approved recipes and a diet manual, which were not adequately followed. The lack of training and adherence to IDDSI guidelines resulted in the potential for residents to experience difficulty swallowing, decreased food intake, and unintended weight loss. The deficiency affected 8 out of 88 residents on a pureed diet, posing a risk of choking and aspiration.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as evidenced by multiple observations of unclean kitchen equipment and areas. Dust buildup was noted on the vents of the reach-in freezer, kitchen vents, and kitchen hood, with the Dietary Supervisor (DS) acknowledging the potential for bacterial growth and cross-contamination. The ice machine also had a significant dirt buildup, which the DS attributed to corrosion and calcium deposits, posing a risk of contamination to the ice consumed by residents. Further deficiencies were observed in the handling and storage of kitchen equipment and utensils. Pans were stacked wet, which the DS admitted could lead to bacterial growth. Dented cans were found stored with non-dented cans, contrary to the facility's policy, raising concerns about potential contamination from metal particles. Additionally, staff failed to adhere to proper handwashing protocols, with instances of staff handling food and clean dishes after touching dirty surfaces without washing their hands, increasing the risk of cross-contamination. The facility also failed to ensure that equipment and utensils were smooth and easy to clean. The can opener blade was chipped, storage racks had peeling paint, and resident trays were cracked, all of which could harbor bacteria. The scoop storage was rusted, and the freezer lacked a thermometer for temperature monitoring, which is crucial for preventing food spoilage. The emergency water storage area was cluttered with trash, and storage racks were not elevated to the required height, hindering proper cleaning and increasing the risk of contamination.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor the rights and dignity of two residents, leading to deficiencies in their care. For one resident, a Certified Nursing Assistant (CNA) was observed watching television on her personal cellular phone with earphones in both ears while feeding the resident. This action compromised the resident's safety and dignity, as the CNA admitted she would not have been able to respond if the resident choked. The CNA acknowledged that this was not an acceptable practice and did not honor the resident's dignity and well-being. Additionally, the facility did not ensure that a bioethics committee meeting was held for the same resident, who was deemed unable to make medical decisions. Despite the resident's cognitive skills being intact according to a previous assessment, a later History and Physical indicated the resident lacked decision-making capacity. The facility administered psychotropic medication without consulting a responsible party or representative, as the resident did not have a public guardian or responsible party to make medical decisions on their behalf. For another resident, the facility also failed to obtain a public guardian or hold a bioethics committee meeting before administering psychotropic medication. This resident was diagnosed with schizophrenia, anxiety disorder, and depression, and was deemed unable to make medical decisions. The Social Services Director admitted that an application for public guardianship should have been initiated earlier, and the resident's right to have sound medical decisions made on their behalf was not honored. The facility's policies required informed consent from a representative if a resident was not capable of giving consent, which was not followed in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for the administration of psychotropic medications was properly obtained for two residents, Resident 3 and Resident 4. Resident 3, who was diagnosed with schizoaffective disorder and other conditions, was administered haloperidol without informed consent. Despite having intact cognitive skills for daily decision-making according to the Minimum Data Set, Resident 3's History and Physical indicated a lack of capacity to make medical decisions. The Social Services Director confirmed that Resident 3 did not have a responsible party or public guardian, and the bioethics committee should have been involved before any medical decisions were made. However, this process was not followed, and informed consent was not obtained for the administration of psychotropic medication. Resident 4, diagnosed with schizophrenia, anxiety disorder, and depression, also did not have informed consent properly documented for psychotropic medication administration. The Minimum Data Set indicated severe cognitive impairment, and the History and Physical confirmed the resident's incapacity to make medical decisions. Despite this, the informed consent form for Risperdal was incomplete, and consent for haloperidol was incorrectly obtained from the resident himself, who was not capable of providing it. The Social Services Director noted that Resident 4 lacked a responsible party or public guardian, and the bioethics committee should have been consulted, but this step was not taken. The facility's policies required informed consent to be obtained from a resident's representative if the resident was not capable of giving consent. In both cases, the facility did not adhere to its policies, as informed consent was not properly obtained or documented, and the necessary involvement of a bioethics committee or responsible party was overlooked. This led to the administration of psychotropic medications without proper consent, violating the residents' rights to be fully informed and involved in their care decisions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, leading to a potential delay or inability for these residents to obtain necessary care and services. Resident 72, who has a history of type 2 diabetes mellitus, chronic kidney disease, muscle wasting, and difficulty walking, was observed on multiple occasions with the call light hanging from the bedside nightstand, out of reach. Despite care plans indicating the need for the call light to be within reach to prevent falls, observations and interviews with staff confirmed that the call light was not accessible to Resident 72. Similarly, Resident 86, who suffers from dementia, dysphagia, muscle wasting, and major depressive disorder, was observed with the call light on the floor behind the bed, making it inaccessible. The resident's care plan also emphasized the importance of having the call light within reach to anticipate and meet care needs. Observations and staff interviews confirmed that the call light was not within reach, which could prevent the resident from calling for help when needed. Interviews with CNAs and LVNs revealed that the staff acknowledged the importance of having the call light within reach for resident safety and communication. The facility's policy and procedures, as well as job duties for CNAs, require that the call light be kept within easy reach of residents. However, the observations indicated a failure to adhere to these guidelines, resulting in a deficiency in providing adequate care and safety for the residents involved.
Failure to Notify Physician of Subtherapeutic Phenobarbital Levels
Penalty
Summary
The facility failed to notify the physician of a resident's low blood level concentration of phenobarbital, a medication used to control seizures, for one of the sampled residents. This oversight was identified during a review of the resident's records, which showed that the resident had a history of epilepsy and other medical conditions. The resident's phenobarbital level was found to be subtherapeutic, with a reading of 8 ug/mL, significantly below the normal range of 14-40 ug/mL. Despite this, there was no documentation indicating that the physician was informed of the low levels, which could have allowed for an adjustment in the medication dosage. The deficiency was further highlighted when the resident experienced seizures, as documented in an SBAR note, which described the resident exhibiting stiff jerking movements and being difficult to arouse. The seizures necessitated emergency intervention, including the application of oxygen and calling 911. Interviews with the RN and the DON confirmed that the low phenobarbital levels were not communicated to the physician, which was against the facility's policy to notify the physician of any subtherapeutic laboratory results. This failure to communicate critical information potentially contributed to the resident's seizure episode.
Inaccurate MDS Coding for Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident was accurately coded to reflect the resident's oral and/or dental status. Specifically, the MDS for a resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression, and anxiety, was inaccurately coded as not having any oral and/or dental issues. However, during an observation and interview, it was noted that the resident did not have her upper and bottom teeth, and her dentures were placed on her bedside table. This discrepancy was confirmed by the Minimum Data Set Nurse (MDSN 1), who acknowledged that the MDS section L was incorrectly coded and should have reflected the resident's use of dentures. The inaccuracy in the MDS assessment resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS), which had the potential to negatively affect the resident's care plan and delivery of necessary care and services. The facility's policy and procedure titled 'Certifying Accuracy of the Resident Assessment' requires qualified professionals to certify the accuracy of the MDS sections they complete. The failure to accurately code the resident's oral and/or dental status in the MDS highlights a deficiency in the facility's assessment process.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident, omitting diagnoses of depression and anxiety. This oversight was identified during a review of the resident's Face Sheet and Minimum Data Set (MDS), which indicated active diagnoses of depression and anxiety. The PASARR Level I, dated several months prior, incorrectly stated that the resident did not have a serious mental illness. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged the error and its potential impact on the resident's care. The resident, who was admitted and later readmitted to the facility, had a medical history that included depression, anxiety, hypertension, dementia, and diabetes mellitus. The inaccurate PASARR Level I screening increased the risk that the resident would not receive the necessary specialized care and services for their mental health conditions, as the facility's policy required a Level II review for residents with serious mental disorders. The DON emphasized the importance of an accurate PASARR to ensure appropriate care and prevent a decline in the resident's health and well-being.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for three residents, leading to potential negative impacts on their health and well-being. Resident 48, who was admitted with chronic obstructive pulmonary disease and depression, did not have a care plan for the use of dentures. Despite the resident's cognitive skills being intact and requiring moderate assistance for activities of daily living, the absence of a care plan for dentures was noted during an observation and interview. The Minimum Data Set Nurse confirmed that there was no care plan in place, which should have been initiated upon admission to ensure quality care. Resident 10, diagnosed with epilepsy and other conditions, had a care plan for seizures that was not properly implemented. The facility failed to notify the resident's physician about a low blood level concentration of Phenobarbital, a medication used to control seizures. This oversight was discovered during a review of the resident's laboratory results and nursing progress notes, which did not indicate any physician notification. As a result, Resident 10 experienced seizures, and the Quality Assurance Nurse acknowledged that the lack of physician notification increased the likelihood of seizures or falls due to seizures. Resident 242, who was dependent on supplemental oxygen due to COPD and other health issues, did not have a care plan for oxygen administration. Despite being observed receiving oxygen via nasal cannula, the Licensed Vocational Nurse confirmed the absence of an oxygen care plan. The Director of Nursing stated that all residents receiving oxygen should have a care plan, and the facility's policy indicated that a comprehensive, person-centered care plan should be developed within a specified timeframe. The lack of a care plan for oxygen administration could delay necessary monitoring and safety interventions for Resident 242.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for a resident, specifically by not keeping the resident's fingernails clean and neat. During observations, the resident was found with long fingernails and a black substance underneath them. The resident expressed that she could not remember the last time her fingernails were cleaned or cut and expressed a desire to have them trimmed and cleaned. The resident's medical history includes dementia, dysphagia, muscle wasting, and major depressive disorder, and she requires maximal assistance from staff for activities of daily living due to severely impaired cognitive skills. The facility's policy and procedure require that residents' fingernails be cleaned daily and trimmed regularly to prevent infections and potential injuries. However, observations and interviews with staff revealed that the resident's fingernails were not being maintained as per the facility's guidelines. A CNA acknowledged the responsibility of CNAs to clean and trim residents' fingernails and recognized the importance of maintaining hygiene to prevent bacterial growth and potential infections. The Director of Staff Development also confirmed that it was the CNAs' duty to ensure residents' fingernails were cleaned daily and trimmed as needed.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with severe, painful bilateral hand contractures by not applying hand splints as ordered by the physician. The resident, who had diagnoses including dysphagia, schizoaffective disorder, and adult failure to thrive, was ordered to have bilateral hand rolls applied for four to five hours every day, five days a week. However, observations and interviews revealed that the resident did not have the hand splints applied on the observed day, and the Restorative Nurse Aide (RNA) responsible for the task admitted to not having enough time to complete it, resulting in inaccurate charting. The RNA's failure to apply the hand splints as ordered was corroborated by the resident's report of not receiving the splinting service and experiencing pain and occasional bleeding in the inner palm. The Certified Occupational Therapy Assistant confirmed the importance of hand splints in preventing the worsening of contractures and easing pain. The facility's policies required that restorative nursing care be provided as needed and that charting must align with physician orders, which was not adhered to in this case.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to maintain a safe environment for Resident 72 by not adhering to its fall prevention policy. Resident 72, who was at high risk for falls due to cognitive impairment and mobility issues, was found with a call light device out of reach and obstacles such as cords and shoes on the floor next to the bed. These conditions were observed on multiple occasions, and staff acknowledged that the call light should have been within reach and the floor free of tripping hazards to prevent falls. Resident 80's bathroom presented an accident hazard due to a leaking sink and drainpipe, which resulted in water accumulating on the floor. Despite Resident 80's report of the issue to the nursing staff, the leak was not addressed, leaving the resident at risk of slipping and falling. The maintenance supervisor confirmed the unsafe condition, noting that the water on the floor and the use of a plastic container to catch the leak were hazardous. CNA 3 compromised Resident 3's safety by watching television on a personal cellular phone with earphones in both ears while feeding the resident. Resident 3, who required substantial assistance with eating due to dysphagia, was at risk of choking, which could have gone unnoticed due to the CNA's inattention. The CNA admitted that this was not an acceptable practice, as it prevented her from adequately monitoring the resident's condition during feeding.
Failure to Display Oxygen Signage for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to place oxygen signage at the doorway for a resident receiving oxygen therapy, which is a requirement for safety precautions. Resident 242, who was receiving oxygen at two liters per minute via nasal cannula, did not have the necessary oxygen signage outside their room or in the room itself. This oversight was observed during a review of the resident's records and confirmed through interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The LVN acknowledged the absence of the signage and emphasized its importance for safety, particularly in the event of a fire. Resident 242 had multiple diagnoses, including chronic obstructive pulmonary disease, respiratory failure, and dependence on supplemental oxygen, which necessitated the use of oxygen therapy. The facility's policy on oxygen administration, revised in October 2010, clearly states that an 'Oxygen in Use' sign should be placed on the outside of the room entrance door and over the resident's bed. Despite this policy, the required signage was not in place, as confirmed by the DON, who stated that nursing staff should have placed the signage immediately upon the resident being placed on oxygen therapy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer specifications for two residents, leading to potential adverse effects. Resident 50, who has a history of atherosclerosis and Type 2 Diabetes Mellitus, was observed swallowing an aspirin 81 mg chewable tablet without chewing it, contrary to the manufacturer's instructions. This oversight by the Licensed Vocational Nurse (LVN) increased the risk of the medication being ineffective, potentially leading to a stroke or heart attack. Resident 69, diagnosed with schizophrenia and major depressive disorder, received an incorrect dosage of quetiapine due to discrepancies between the medication card and the electronic Medication Administration Record (eMAR). The medication card indicated a dose of 12.5 mg, while the eMAR showed a 25 mg dose. This inconsistency was not clarified with the physician, resulting in the resident not receiving the appropriate dose, which could have failed to manage symptoms effectively. Additionally, the facility did not clarify the frequency of administration for Resident 30's polyethylene glycol order, which was prescribed for constipation. The lack of a specified frequency in the order posed a risk of administering the medication inappropriately, potentially causing diarrhea, dehydration, or other adverse effects. The Director of Nursing acknowledged these issues, noting that medication orders should have clear dosing frequencies and that discrepancies between medication cards and eMAR should be resolved to prevent medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in an 8% error rate. This deficiency was observed in the cases of two residents. For the first resident, the facility did not ensure that an aspirin 81 mg chewable tablet was administered correctly. The resident, who had moderate cognitive impairment and required supervision for daily activities, was observed swallowing the chewable aspirin tablet whole, rather than chewing it as required. This error was acknowledged by the Licensed Vocational Nurse (LVN) responsible for the administration, who admitted that the resident was not instructed to chew the tablet, potentially affecting the medication's efficacy. In the second case, the facility failed to clarify a physician's order for quetiapine, a medication used to treat schizophrenia, before administration. The resident, who had severe cognitive impairment and required significant assistance with daily activities, was administered a 12.5 mg dose of quetiapine, which did not match the physician's order of 25 mg. The discrepancy between the medication card and the electronic medication administration record (eMAR) was identified during a medication reconciliation review. The LVN involved recognized the error and stated that the physician would be contacted for clarification, as the resident did not receive the appropriate dose as ordered. The Director of Nursing (DON) confirmed the errors, noting that the aspirin should have been administered as a chewable tablet and that the quetiapine order required clarification. The facility's policies and procedures for medication orders and administration were reviewed, highlighting the need for accurate recording and administration of medications as prescribed. The DON acknowledged that the nurse responsible for entering the quetiapine order no longer worked at the facility, but emphasized the importance of accurate order entry and administration according to physician instructions.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident, identified as Resident 69, from verbal and physical abuse by another resident, identified as Resident 73. Resident 69, who was admitted with conditions including hemiplegia, schizophrenia, and major depressive disorder, was severely impaired cognitively and required maximal assistance for daily activities. An incident occurred where Resident 73, who had intact cognitive skills and required moderate assistance, verbally abused Resident 69 by yelling curse words and physically abused him by throwing water. This altercation was reportedly triggered by Resident 69 eating Resident 73's snacks. The Director of Nursing and a Licensed Vocational Nurse confirmed the incident, noting that Resident 73's actions constituted verbal and physical abuse. The facility's policy on preventing resident abuse, which mandates an abuse-free environment, was not adhered to in this case. The facility's failure to prevent this abuse was documented in the report, highlighting a deficiency in ensuring residents' rights to be free from abuse were upheld.
Failure to Report Resident-to-Resident Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical and verbal abuse involving two residents within the required timeframe. Resident 69, who has severe cognitive impairment and requires maximal assistance for activities of daily living, reported that his roommate, Resident 73, yelled at him, used curse words, and threw water at him. Resident 73, who has intact cognitive skills and requires moderate assistance, admitted to the altercation, stating he was upset because Resident 69 was eating his snacks. The Director of Nursing (DON) confirmed that the incident constituted resident-to-resident verbal and physical abuse and should have been reported immediately. However, Licensed Vocational Nurse (LVN 6) witnessed the incident but did not report it to the DON, Administrator, or the California Department of Public Health (CDPH) as required. The facility's policy mandates immediate reporting of any signs of abuse to supervisors and the DON, and the incident should have been reported to the appropriate authorities within two hours. The failure to report the incident in a timely manner resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents at risk for further abuse. The facility's policies on abuse recognition, investigation, and reporting were not followed, leading to this deficiency.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for investigating resident-to-resident abuse, resulting in a deficiency. The incident involved two residents, one of whom had severe cognitive impairment and required maximal assistance for activities of daily living, while the other had intact cognitive skills and required moderate assistance. The incident occurred when the resident with intact cognitive skills became upset over the other resident eating his snacks, leading to verbal abuse and physical aggression, including throwing water and using curse words. The Director of Nursing acknowledged that the actions constituted verbal and physical abuse and should have been investigated immediately, as per the facility's policy. A Licensed Vocational Nurse witnessed the incident but failed to report it promptly, which delayed the investigation and potentially exposed other residents to the risk of abuse. The facility's policy, revised in 2014, mandates that all reports of resident abuse be thoroughly and promptly investigated, which was not adhered to in this case.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of room space per resident for 22 out of 40 rooms, as observed during a survey. The rooms in question were identified in a Room Waiver Request letter dated 2/11/2025, which acknowledged that these two-person rooms did not meet the space requirement. Despite this deficiency, the letter claimed that the waiver did not adversely affect the health and safety of the residents or impede their ability to attain their highest practicable well-being. During an interview, the Administrator stated that the impact on resident care was minimal and assured that patient care and safety would not be compromised. The Administrator also noted that all 22 rooms had sufficient space for necessary medical equipment such as Hoyer lifts, wheelchairs, and gurneys. Observations made throughout the survey period did not reveal any adverse effects on residents' care, privacy, health, or safety related to the reduced living space. The facility's policy on providing a safe, clean, comfortable, and homelike environment was also reviewed.
Failure to Notify Physician and Assess Wandering Risk
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, specifically the resident's wandering behaviors on three separate occasions. The resident, who was diagnosed with dementia and other behavioral disturbances, exhibited wandering behaviors on 12/30/2024, 1/1/2025, and 1/4/2025. Despite these incidents being documented in the nursing progress notes, the Licensed Vocational Nurse responsible for the notes did not inform the physician, citing forgetfulness as the reason. This lack of communication with the physician is a violation of the facility's policy, which mandates notifying the attending physician of any significant change in a resident's condition. Additionally, the facility did not conduct an Interdisciplinary Team (IDT) meeting to assess the resident's risk for wandering, as required by their own policies. The Minimum Data Set Nurse Coordinator acknowledged that the IDT should have assessed the resident's risk upon admission, readmission, and when changes in condition were observed. The Director of Nursing also confirmed the importance of IDT meetings in modifying care plans to address such behaviors. The facility's failure to hold an IDT meeting and assess the resident's wandering risk further contributed to the deficiency.
Failure to Prevent Resident Abuse Due to Inaction on Physician's Order
Penalty
Summary
The facility failed to prevent physical abuse for two residents due to inadequate response to a physician's order and lack of communication among staff. A physician's order was issued on 12/3/2024 to send a resident to a General Acute Center Hospital (GACH) for psychiatric evaluation if further aggressive behavior was observed. However, this order was neither documented nor executed, leading to subsequent aggressive incidents involving the resident. On 12/4/2024 and 12/5/2024, the resident displayed episodes of physical aggression, but the physician was not notified, and the order to send the resident for evaluation was not carried out. This oversight resulted in the resident pushing another resident in the hallway on 1/21/2025 and hitting a different resident on the head multiple times on 1/23/2025. These incidents were unprovoked and led to injuries, highlighting the facility's failure to follow through with the physician's directive and communicate effectively among staff. Interviews with nursing staff and the Director of Nursing (DON) revealed that the licensed nurses did not document or act on the physician's order, assuming it had already been addressed. The facility's policy on abuse prevention and medication orders was not adhered to, contributing to the repeated aggressive incidents and placing residents at risk of further abuse.
Failure to Implement Care Plan for Wandering Resident Leads to Altercation
Penalty
Summary
The facility failed to initiate and implement a care plan for a resident with known wandering behaviors, which led to a physical altercation. Resident 2, who was admitted with diagnoses including dementia with behavioral disturbances and severe cognitive impairment, was noted to wander at night according to nursing progress notes. Despite these observations, no care plan was created to address the wandering behavior, as confirmed by an LVN who acknowledged the oversight. This lack of a care plan meant that no interventions were in place to prevent incidents such as the one that occurred. The incident involved Resident 2 wandering into another resident's room, resulting in a physical altercation where Resident 1 struck Resident 2 multiple times. Resident 1, who also had severe cognitive impairment and required substantial assistance for daily activities, was diagnosed with schizoaffective disorder and other mental health conditions. The facility's policies required comprehensive care plans and safety interventions, but these were not implemented for Resident 2, leading to the altercation and subsequent injuries.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in significant harm. Resident 1, who had a history of severe cognitive impairment and behavioral issues, struck Resident 7 in the face without provocation, causing an acute depressed nasal bone fracture. Despite being monitored for sudden mood shifts and aggressive behavior, Resident 1 was able to physically assault Resident 7 in the hallway, as witnessed by a dietary aide. Resident 7, who also had severe cognitive impairment and required assistance with daily activities, was unable to defend himself or report the incident effectively. In a separate incident, Resident 5, who had a history of mental health disorders and behavioral issues, slapped Resident 6 in the face near the vending machines. Resident 5 was supposed to be under one-to-one supervision due to her behavioral patterns, but the activities aide left her unsupervised for a brief period, during which the assault occurred. Resident 6, who had mild cognitive impairment and required assistance with daily activities, was unable to prevent the assault and later expressed feeling betrayed by Resident 5, whom he considered a friend. The facility's policy on abuse prevention and prohibition was not effectively implemented, as evidenced by these incidents of resident-to-resident physical abuse. The policy clearly stated that the facility did not condone any form of abuse and promoted an environment free from mistreatment. However, the failure to adequately supervise residents with known behavioral issues and cognitive impairments led to these incidents of physical abuse, violating the residents' right to a safe and abuse-free environment.
Failure to Document Resident Altercations and Care Interventions
Penalty
Summary
The facility failed to meet professional standards of quality care for seven out of ten residents by not documenting changes in condition and nursing interventions. Specifically, there was a lack of documentation regarding incidents of resident-to-resident altercations and the necessary follow-up care. For instance, Resident 1 was involved in multiple altercations with other residents, including slapping a hat off another resident and striking another resident in the face, yet these incidents were not properly documented in the nursing progress notes. Additionally, the facility did not complete documentation of nursing interventions for several residents on their Medication Administration Records (MARs). This included monitoring for adverse side effects of medications, behavioral changes, and pain assessments. Residents with complex medical and psychiatric conditions, such as dementia, schizophrenia, and bipolar disorder, were not adequately monitored, as evidenced by missing documentation on specific dates for required interventions. The lack of documentation extended to incidents where residents reported being hit or spat on by other residents. These incidents were not recorded in the nursing progress notes, and the required 72-hour monitoring after such altercations was not documented. The Director of Nursing acknowledged that the absence of documentation could lead to missed changes in residents' conditions and potentially delay necessary care, increasing the risk of further altercations.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was on one-to-one (1:1) supervision, resulting in an incident where the resident slapped another resident. The resident on 1:1 supervision had a history of Parkinson's disease, schizoaffective disorder, bipolar disorder, restlessness, and agitation, and was known to have sudden angry outbursts. Despite these conditions, the resident was left unsupervised near the vending machines, leading to the altercation. The incident occurred when the resident on 1:1 supervision slapped another resident because the latter refused to light a cigarette. The staff member responsible for the 1:1 supervision, an Activities Aide, left the resident alone to inform the charge nurse of her need to leave work. During this time, no other staff was present to supervise the resident, which directly led to the incident. The lack of supervision was acknowledged by the Activities Aide, who admitted that leaving the resident alone was against protocol. Interviews with the Director of Staff Development and the Director of Nursing confirmed that staff providing 1:1 supervision should not leave the resident unsupervised at any time. The facility's policy on safety and supervision of residents emphasized the need for targeted interventions to reduce risks, including adequate supervision. The failure to adhere to these protocols resulted in the incident, highlighting a deficiency in the facility's supervision practices.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to implement its policy and procedure for notifying a resident's physician of a significant change in condition, as evidenced by the case of a resident who experienced a decrease in oxygen saturation levels. Despite the resident's oxygen saturation dropping to 84% and not improving with increased oxygen administration, the physician was not notified in a timely manner. The resident was hypoxic and only responsive to tactile stimuli, leading to a delay in transferring the resident to a general acute care hospital for evaluation and treatment. Additionally, the facility did not adhere to its policy regarding neurological assessments following an unwitnessed fall. The resident refused the 72-hour neurological checks and body check assessments, but the facility failed to notify the physician of these refusals. The lack of completed assessments and physician notification put the resident at risk for undetected neurological changes and potential complications from the fall. Furthermore, the facility did not conduct necessary skin assessments for the resident, who had a history of cellulitis and venous ulcers. The resident refused skin checks during activities of daily living, and the facility did not notify the physician of these refusals. This oversight resulted in the resident's skin condition not being adequately monitored, potentially leading to skin breakdown and impaired skin integrity.
Failure to Revise Care Plan for Resident Refusing Skin Checks
Penalty
Summary
The facility failed to revise the person-centered care plan for a resident who consistently refused skin check assessments during activities of daily living. This resident, who was admitted with diagnoses including cellulitis, acute embolism, thrombosis, and peripheral vascular disease, had severely impaired cognition and required moderate assistance with daily activities. Despite these needs, the resident refused skin observations on multiple occasions, which were documented in the Skin Observation record. Interviews with CNAs revealed that the resident was very independent, ambulatory, and refused assistance with ADLs, preferring to manage personal hygiene independently. The Director of Nursing acknowledged that the resident's care plan should have been revised to reflect the ongoing refusal of skin assessments. The facility's policy indicated that care plans should be revised as the resident's condition changes, but this was not done for the resident in question. The lack of a revised care plan meant there was no guideline for assessing and managing the resident's skin integrity, potentially leading to mismanagement of care. The deficiency was identified through interviews and record reviews, highlighting a failure to communicate the resident's ongoing refusal to the care team and to develop further interventions to prevent skin breakdown and promote healing.
Failure to Administer Ordered Wound Care
Penalty
Summary
The facility failed to provide ordered wound care treatments for a resident on two specific dates, 12/7/2024 and 12/28/2024. The resident, who was admitted with multiple diagnoses including cellulitis, acute embolism, thrombosis, and peripheral vascular disease, had four venous ulcers and an infection on the left foot. The Minimum Data Set indicated the resident's cognition was severely impaired, and they required moderate assistance with daily activities. The ordered wound care treatments included cleansing the wounds with normal saline, applying Silvadene and zinc oxide creams, and covering with absorbent dressing and kerlix. The Treatment Nurse (TN) acknowledged that the resident did not receive the ordered wound care on the specified dates, as indicated by empty boxes on the Treatment Administration Record (TAR). The TN stated that the resident's wounds had heavy drainage, making daily wound care essential to prevent worsening of the wounds. The TN also mentioned that other licensed nurses were responsible for administering the treatment when the TN was not present, and there was no record of the resident refusing treatment on those days. Interviews with the TN and a Registered Nurse (RN) confirmed that the wound care treatments were crucial due to the size and nature of the resident's wounds. The facility's policy and procedure for wound care emphasized the importance of following physician orders and documenting the care provided. The failure to administer the ordered treatments on the specified dates was a deviation from the facility's policy and had the potential to negatively impact the resident's wound healing process.
Failure to Report and Assess Falls in a Timely Manner
Penalty
Summary
The facility failed to ensure the safety and proper care of two residents, leading to deficiencies in accident prevention and response. Resident 1 experienced an unwitnessed fall, which was not reported by the CNAs to the licensed nurses, resulting in a two-hour delay in assessment and initiation of a 72-Hour Neurological Check. The CNAs moved Resident 1 before a licensed nurse could assess him, contrary to facility procedures, which require immediate reporting and assessment by a licensed nurse to prevent further injury. Resident 1, who had a history of ataxia, epilepsy, dementia, and was at high risk for falls, was found on the floor by CNAs who assisted him back to bed without notifying a licensed nurse. This oversight led to a delay in necessary medical evaluations and interventions. The facility's policy mandates that CNAs report falls immediately and refrain from moving residents until a licensed nurse has conducted an assessment, which was not followed in this case. Resident 2 also experienced a fall and subsequent refusal of neurological assessments, which were not conducted according to the required schedule. The licensed nurse failed to adhere to the timing of the assessments, which are crucial for detecting neurological changes after a fall. The incomplete 72-Hour Neurological Check for Resident 2 further exemplifies the facility's failure to ensure timely and adequate supervision and care following accidents.
Missing Psychiatry Note in Resident's Chart
Penalty
Summary
The facility failed to ensure that a psychiatry note for one of the residents was readily available in the resident's physical chart. This deficiency was identified during a review of the resident's clinical records, which revealed the absence of a psychiatry evaluation note. The resident, who was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, had severe cognitive impairment as indicated in their Minimum Data Set. The Order Summary Report suggested that the resident may require a psychiatry evaluation and follow-up treatment, yet no such notes were found in the clinical records. Interviews with the Medical Records Director (MDR) and a Registered Nurse (RN) revealed that the psychiatry team typically emails their notes to the medical records department, which then prints and places them in the resident's physical chart. However, in this case, the psychiatry notes were not present, and the MDR was unaware of how this oversight occurred. The RN acknowledged that the absence of these notes could impact the care provided to the resident, as other staff members or doctors might need the psychiatrist's evaluation to inform treatment decisions.
Incorrect MDS Coding for Resident Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for a resident with diagnoses including schizoaffective disorder, anxiety disorder, and diabetes mellitus. The resident's care plan documented behavior problems such as auditory hallucinations and episodes of yelling at staff, which were related to their schizoaffective disorder. However, during the quarterly MDS assessment, these behaviors were not properly coded in section E (behavior), with hallucinations marked as 'None of the Above' and verbal behavioral symptoms directed toward others marked as 'not exhibited.' The MDS nurse acknowledged during interviews and record reviews that these behaviors should have been coded on the MDS but were missed. The facility's policy indicated that the resident assessment coordinator is responsible for ensuring the accuracy of resident assessments, and that the person completing the MDS must attest to its accuracy. This deficiency resulted in the transmission of incorrect behavioral data to CMS for the resident.
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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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