Santa Monica Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1338 20th Street, Santa Monica, California 90404
- CMS Provider Number
- 555808
- Inspections on file
- 122
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Santa Monica Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain clean and sanitary ventilation intake screens in resident rooms, as evidenced by thick dust accumulation on intake screens located above the beds of two residents. One resident reported the dust had been present for a long time and was concerned about inhaling it, while another resident, in the facility for several years, stated he had never seen the screens cleaned. The Maintenance Supervisor confirmed the presence of dust on an intake screen in another room and acknowledged the potential for allergen exposure, despite a facility policy requiring a safe, clean, and sanitary homelike environment.
Surveyors found that resident food storage practices did not follow facility P&P in multiple nutrition rooms. On two floors, open dry food items such as cereal and chips were stored in cabinets without labels or dates, and multiple bags and containers of resident food in refrigerators lacked required resident names, received dates, and open dates. Refrigerators were also overcrowded, limiting air circulation, despite posted instructions that all resident food must be labeled with name, date, expiration date, and discarded after 72 hours, and a written P&P requiring proper coverage, dating, labeling, and avoidance of overcrowding.
Staff failed to respect two English-speaking residents’ rights to dignity and communication when staff spoke to each other in a foreign language while providing care. Both residents had documented English as their primary language and required varying levels of assistance with ADLs and bed mobility; one had intact cognition and the other had mild memory problems. Each resident reported hearing staff speak in a language they did not understand during care, with one expressing concern that staff could be talking about her. A CNA acknowledged that staff should not speak a different language than the one the resident speaks, and the facility’s Resident Rights policy requires employees to treat residents with kindness, respect, and dignity and to support them in exercising their rights.
A resident with encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, documented impaired decision-making capacity, and memory problems was assessed as being at risk for elopement and had a care plan calling for a Wanderguard bracelet, frequent visual checks, and staff awareness of elopement risk. A nurse obtained a physician order for a Wanderguard and attempted to obtain consent from the resident’s representative, but follow-up was left to the next shift and not completed. No order for Wanderguard use or monitoring of wandering behaviors was entered, and no related monitoring or documentation occurred. The resident subsequently eloped, demonstrating that the facility did not implement the care-planned interventions for wandering risk.
Staff failed to follow facility linen-handling policies and infection control practices. An in-service on proper linen handling required storing clean linen in designated clean areas or carts, keeping it covered during transport, and only bringing needed amounts into each room, but one CNA was not listed as having attended. A resident with multiple serious conditions and total dependence on staff had a large open plastic bag of mixed clean linen items stored on the nightstand, which a CNA used as a central supply for all assigned residents by transferring linen from that bag into other rooms. Another CNA described handling linen separately for each resident, while an LVN stated CNAs were educated to keep separate linen bags in each room and acknowledged that linen brought into a room is considered dirty. Surveyors also observed two linen carts with covers flipped up, leaving clean linen exposed, contrary to policy requiring clean linen to be protected from environmental contamination.
Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
A resident with schizophrenia, bipolar disorder, severe cognitive impairment, and documented medical noncompliance repeatedly refused ordered Depakote and risperidone over multiple days, including several stretches of three or more consecutive refusals. The care plan required notifying the physician of risks related to non-compliance, and facility policy required physician notification and documentation when consecutive doses of vital medications were refused. Review of the MAR and nursing notes, along with interviews with an LVN and the DON, showed that no physician notification or response was documented despite these repeated refusals, resulting in a significant medication error.
A resident with ESRD and dependence on hemodialysis, along with other serious comorbidities, had physician orders for thrice-weekly dialysis with specified chair times and transportation schedules. The resident’s care plan and clinical documentation show that multiple dialysis sessions were missed because transportation either did not arrive or would arrive too late, and on one occasion due to an expired PCS form that had not been timely completed and signed, which was required for insurance-authorized transport. Staff interviews confirmed that social services relied on PCS-based insurance transportation, that some contracted transportation companies failed to show without warning, and that nursing staff coordinated orders and transportation with social services, yet these processes did not prevent the resident from missing several medically necessary dialysis appointments despite facility policies stating that social services would help obtain transportation and assist in arranging appointments.
A resident with a history of cerebral infarction, aphasia, hemiplegia, and hemiparesis, but no documented cognitive impairment, and the resident’s POA were not provided with required written notices of Medicaid/Medicare coverage, share of cost (SOC), or monthly billing statements. Due to ownership changes and high turnover in the business office and social services, the facility did not update records or send periodic SOC notifications, and the business office could not verify that any monthly statements or SOC notices had been mailed. The POA reported never receiving statements or SOC information and only learned of four months of unpaid SOC when contacted by a third‑party company, despite facility policy requiring monthly itemized billing and written notice before changes in non‑covered costs.
Staff failed to follow hand hygiene standards when two CNAs fed a dependent, cognitively impaired resident with multiple diagnoses, including anoxic brain damage, UTI, immune disorder, and heart failure. One CNA placed a bed remote on the floor, then on the bed without cleaning it, and proceeded to feed the resident without hand hygiene; another CNA entered from the hallway and began to feed the resident without hand hygiene. Both CNAs acknowledged not performing hand hygiene, while the ADON and IP confirmed that hand hygiene is a required standard precaution per facility policy and CDC-based infection prevention guidelines.
Surveyors found that the facility did not develop required discharge care plans for three cognitively intact residents with multiple comorbidities, including fractures, OA, morbid obesity, DM, dysphagia, and serious mental health conditions. Each resident required extensive or total assistance with toileting, bathing, and transfers, yet no discharge care plans were present in their records. The DSS reported that discharge planning is supposed to begin at admission and be updated regularly, while the MRA confirmed that no discharge care plans existed for these residents.
The facility did not report an allegation of verbal and physical abuse between two residents to the appropriate authorities within the required two-hour timeframe, despite being aware of the incident and having a policy mandating immediate reporting. Both residents had significant medical conditions and required staff assistance, and the delay in reporting was confirmed through staff interviews and record review.
The facility did not ensure that the Social Services Director assessed or documented the psychosocial well-being of several residents following incidents of alleged physical and verbal abuse. Despite incidents involving law enforcement and staff-witnessed verbal altercations, affected residents did not receive required follow-up or support, and the lack of documentation was confirmed by staff interviews. This failure was inconsistent with facility policy and job expectations.
Two residents with significant mobility and health needs experienced repeated delays in staff response to their call lights, contrary to facility policy. Both residents reported waiting extended periods for assistance, leading to discomfort and feelings of neglect. Staff interviews confirmed that delayed responses were common, especially during shift changes or when staffing was reduced.
A resident with severe psychiatric conditions and identified as an elopement risk was able to leave the facility without staff notification. Documentation regarding the resident's intent to leave AMA was incomplete, and staff were not consistently monitoring resident whereabouts, especially during shift changes. The resident's absence was discovered during rounds, and their whereabouts remain unknown.
Maintenance staff did not report nonfunctioning thermostats or temperature regulation issues to administration, resulting in the air conditioning being turned off at night and residents experiencing excessive heat. Despite multiple residents with complex medical needs complaining about the temperature, staff failed to offer available portable AC units or follow facility policy for reporting and documentation.
Two residents with significant mobility impairments and intact cognition were forcefully removed from their motorized power wheelchairs by corporate staff, placed into manual wheelchairs without consent or clinical justification, and denied access to their preferred mobility devices. The residents experienced emotional distress, loss of autonomy, and were confined to bed for extended periods, resulting in psychosocial harm.
The facility did not keep the phone ringers at an audible volume at all nursing stations, resulting in staff being unaware of incoming calls until overhead pages were made. LVNs confirmed the phone volumes were turned down, and calls from doctors, family, and patients could not be promptly answered, contrary to facility policy.
A resident with multiple chronic conditions did not receive IV fluids as ordered, with the infusion not running for an extended period and staff unaware of the order. The IV bag remained partially full and uninfused, and the nurse supervisor had not remembered the order, contrary to facility policy requiring proper administration and monitoring of IV therapy.
A resident with multiple complex medical conditions was admitted without the admission agreement being explained or signed at the time of admission, as required by facility policy. The resident's representative did not receive the admission packet until weeks later and experienced delays in getting questions answered about the agreement, resulting in a lack of clarity regarding covered services and payment responsibilities.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were involved in an altercation when one, with a history of wandering and cognitive impairment, entered another's room and accessed personal belongings, leading to the second resident throwing water at the first. Although the incident was documented, staff and administration did not investigate or report the event to required authorities as mandated by facility policy and federal regulations.
A resident with severe cognitive impairment and multiple respiratory conditions did not receive BiPAP therapy as ordered, with compliance reports showing significantly reduced usage time. Staff interviews revealed ongoing issues with the BiPAP machine leaking and alarming at night, and the device was not consistently set up or functioning properly, resulting in the resident not receiving the prescribed respiratory support.
Nursing staff failed to respond promptly to a resident's call light, left a resident in discomfort for an extended period, and did not ensure that registry CNAs were competent in required care skills. Some CNAs lacked proper orientation, did not wear ID badges, and had communication barriers with residents. The facility also lacked a Director of Staff Development to oversee staff training, and competency documentation for registry CNAs was incomplete or missing.
Six residents with physician orders for PT evaluation and treatment did not receive timely assessments due to the facility's lack of a consistent, qualified PT. Staff interviews confirmed that PT evaluations were delayed or missed, with agency PTs only available intermittently. Residents with significant mobility impairments and complex medical needs were left without appropriate rehabilitative services, contrary to facility policy and physician orders.
The facility did not consistently open the dining room for dinner, limiting residents' ability to choose where to eat. Staff interviews confirmed that the dining room was typically only available for lunch, and a resident reported having to eat dinner in his room due to lack of staff support. This practice violated facility policy and residents' rights to self-determination and choice.
The facility did not provide enough nursing staff to keep the dining room open for all meals, resulting in residents only being able to eat lunch in the dining room while breakfast and dinner were served in their rooms. Staff interviews and assignment records confirmed ongoing staffing shortages, and a resident with significant medical needs reported being unable to eat dinner in the dining room due to lack of staff. The DON acknowledged the issue after being informed by the activity director.
A resident with severe cognitive and physical impairments was allegedly pushed from bed by a CNA during ADL care, as reported by a roommate. Despite the allegation, the CNA continued working on the same floor, and the incident was not reported to all required agencies or fully documented according to facility policy. The facility did not submit the investigation findings within the required timeframe, resulting in delayed external review.
The facility did not have a full-time PT on staff after the previous PT resigned, leaving residents with physician-ordered physical therapy without access to these services. Both the OT and DON confirmed that no PT was available, and facility policy requires that specialized rehabilitative services, including PT, be provided by qualified personnel.
A facility with over 120 beds did not have a qualified full-time social worker on staff, as the SSD was absent for an extended period and the SSA, who lacked the required education and experience, assumed the role. A resident with significant medical needs had not met with the SSD since readmission and had not participated in a care plan meeting, contrary to facility policy.
A resident with multiple chronic conditions who required significant assistance with daily activities was left waiting for over 30 minutes after activating the call light for help with personal care. The call light was observed blinking and audible at the nursing station, but staff did not respond promptly, as the CNA was assisting another resident and the LVN only responded after the delay. Facility policy and staff interviews confirmed that call lights should be answered immediately.
A CNA transferred a resident with significant mobility limitations using a mechanical Hoyer lift without the required second staff member, contrary to facility policy and the resident's care plan. The resident, who was fully dependent for ADLs and had multiple medical conditions, was placed at risk due to this action, as confirmed by interviews with the LVN and DON.
A resident with cognitive impairment and multiple medical conditions was allegedly subjected to verbal abuse by a CNA, who reportedly called the resident 'crazy' during an overnight shift. Although the incident was documented and discussed among staff, the required report to public health authorities was not made within the mandated two-hour window, resulting in a delay in external notification.
A resident dependent on staff for care, with multiple medical conditions, experienced ongoing verbal abuse and controlling behavior from her roommate, including being blocked from exiting the room and subjected to derogatory remarks. Despite repeated reports to staff and documentation of the incidents by a CNA, SSA, and RN, the facility did not implement effective interventions beyond offering room changes, which both residents refused. Leadership remained unaware or did not act further, resulting in continued risk of abuse.
A resident with a history of liver transplant and multiple complex medical conditions did not have a care plan addressing the liver transplant. The DON confirmed the absence of this care plan during record review, despite facility policy requiring comprehensive, person-centered care plans for all residents.
A resident with severe cognitive impairment and high elopement risk was not properly identified with an ID wristband, and staff were not informed of the resident's elopement risk or the purpose of the Wanderguard device. The resident was not listed on the CNA assignment sheet, and the CNA caring for the resident was unaware of critical safety information, resulting in a failure to meet professional standards of quality.
A resident with cognitive impairment and multiple diagnoses had a skin tear on the right wrist/hand that was not treated according to physician's orders, which required cleansing, application of xeroform, and covering with a dry dressing. During observation, the wound was left open to air without a dressing, and the LVN was unaware of the required treatment. The DON confirmed that physician's orders should be followed if present.
A resident with severe cognitive impairment and a history of elopement was not properly identified or communicated as an elopement risk to staff. The resident was not listed on the CNA assignment sheet, staff were unaware of the Wanderguard's purpose, and the resident was observed without an ID wristband, all in violation of facility policy and safety protocols.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls resulting in injuries, including a hip fracture requiring surgery. Despite being identified as a fall risk and having a care plan with specific interventions, staff did not consistently implement or revise these interventions after each fall. Environmental hazards, such as urine on the floor and an out-of-reach call light, were present, and staff did not provide the required level of supervision, contributing to the resident's repeated falls and injuries.
Facility staff did not notify the physician or document a change of condition when a resident with multiple chronic conditions complained of a sore throat, swallowing issues, and body itching, despite later testing positive for Pertussis. Staff interviews and record reviews confirmed that required documentation and notification protocols were not followed.
A resident with multiple chronic conditions and severe cognitive impairment had grievances raised by a family member regarding lack of activities and poor communication from staff. Although these concerns were noted in progress notes, the facility did not document or investigate the grievances as required by policy, and the DON confirmed the absence of proper grievance documentation.
Two residents with severe cognitive impairment did not have their personal belongings properly inventoried or returned upon admission, discharge, or transfer. The facility failed to document inventories and obtain required signatures, resulting in missing or unreturned items, as confirmed by the DON.
A resident with multiple chronic conditions and cognitive impairment was admitted without a baseline care plan being developed and implemented within 48 hours, as required. The initial care plans for falls, allergies, pain, and skin integrity were not started until several days after admission, and this delay was confirmed by the DON and facility records.
The facility failed to accommodate the needs and preferences of four residents by not ensuring operational televisions and consistent hot water availability. Several residents reported non-functional TVs for three days, affecting their ability to watch programs. Additionally, issues with hot water availability during showers were reported, with one resident having to shower early to avoid running out of hot water and another expressing reluctance to shower due to cold water. Interviews with staff revealed awareness of these issues, but the facility did not adhere to its policy of accommodating resident needs.
A resident with conditions including spinal stenosis, obesity, and COPD received an opened letter, violating their right to privacy. The facility's Nursing Consultant confirmed that mail should remain unopened, as supported by the facility's policies and the California Standard Admission Agreement for Skilled Nursing Facilities.
A resident with a fracture and low back pain experienced a delay of over one and a half hours in response to a call light request for ice chips. The facility's policy requires immediate response to call lights, but insufficient staffing led to this delay, potentially affecting the resident's quality of life.
The facility did not appoint a licensed administrator as required by the Governing Board, potentially affecting resident care and facility management. The Acting Administrator's license was not posted because he was not appointed due to exceeding the 200-bed supervision limit. Facility policies state that the administrator should be appointed by the governing board and is responsible for daily operations.
The facility did not appoint a licensed administrator as required by the governing board, as observed by the absence of an administrator license on the consumer bulletin board. The Acting Administrator admitted he was not appointed due to exceeding the 200-bed supervision limit. Facility policies state the administrator must be appointed by the governing board and manage daily operations.
The facility failed to maintain proper infection control practices, including improper storage of personal items in the kitchen, inadequate hand hygiene by staff, and improper handling of medical equipment. Staff were also observed wearing N95 masks incorrectly during an influenza outbreak, increasing the risk of infection spread among residents.
The facility failed to maintain accurate and current advance directives for four residents, leading to potential conflicts with their healthcare wishes. Despite the residents' varying cognitive impairments and medical conditions, their advance directives were not documented in their records. Interviews with staff revealed inconsistencies in the process of obtaining and documenting these directives, highlighting a deficiency in the facility's protocol.
Failure to Maintain Clean Ventilation Intake Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain clean and sanitary ventilation intake screens in resident rooms, resulting in thick dust accumulation on the intake screens above the beds of two sampled residents. During an observation in one resident’s room, the ventilation intake screen above the foot of her bed was covered with a thick layer of dust, which the resident confirmed had been present for quite a while and expressed concern about dust potentially falling on her and being inhaled. In another resident’s room, the intake screen above the foot of his bed was also observed with a layer of dust; this resident, who had been at the facility for four years, stated he had never seen anyone clean it. The Maintenance Supervisor observed a similar dust layer on a ventilation intake screen in another room and acknowledged that this condition could expose residents to allergens. These conditions occurred despite the facility’s policy and procedure titled “Homelike Environment,” which states that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management will maximize a clean, sanitary, and orderly environment.
Failure to Label, Date, and Properly Store Resident Food in Nutrition Room Refrigerators
Penalty
Summary
The deficiency involves failure to follow the facility’s P&P for resident refrigerator/freezer storage and food handling in resident nutrition rooms. During an observation and concurrent interview with the Infection Preventionist Nurse (IPN) in the 2nd floor nutrition room, surveyors observed an undated and unlabeled open box of cornflakes and an undated and unlabeled open bag of potato chips stored in a cabinet. The IPN acknowledged these items should not have been stored there in that condition and stated they should have been labeled with the resident’s name and an expiration date, and that everything should have a name and an open date. Further observation in the same 2nd floor nutrition room revealed a variety of bags inside the resident refrigerator that were not appropriately labeled and dated. The IPN verified that the food in the refrigerator should be labeled with the resident’s name and an open date so staff know when to discard it, and stated that they clean it out every three days. In the 3rd floor nutrition room, the resident refrigerator contained an opened plastic to-go container with no resident name or received date, along with various bags of food without proper dates and crowded in the refrigerator, despite a posted sign instructing that all resident food be labeled with name, date, and expiration date and that unlabeled food or food left more than 72 hours would be discarded. Review of the facility’s P&P for Resident’s Refrigerator/Freezer Storage – Dietary Services showed requirements that food items be stored to allow air circulation, avoid overcrowding, not be stored beyond 72 hours from date received, and that all items be properly covered, dated, and labeled with delivery and open dates, which were not followed in these observations.
Failure to Respect English-Speaking Residents’ Communication and Dignity Rights
Penalty
Summary
The deficiency involves staff failing to honor residents' rights to dignity, self-determination, communication, and use of their primary language during care. For Resident 3, the Admission Record dated 3/24/26 showed admission with HTN, anemia, hemiplegia and hemiparesis following a stroke, and identified English as the primary language. An MDS dated 2/18/26 documented intact cognition and a need for supervision, touching assistance, or substantial/maximal assistance with ADLs and bed mobility. During interview, Resident 3 stated she hears everything and has heard staff speaking in other languages among themselves. Resident 5’s Admission Record dated 3/24/26 documented admission with muscle weakness, osteoarthritis of the knee, asthma, spinal stenosis, and lymphedema, and identified English as the primary language. An MDS indicated mild memory problems, a need for set-up or clean-up assistance with eating, and substantial/maximal assistance to dependence for other ADLs and bed mobility. During interview, Resident 5 reported that two staff members were in her room that morning speaking a foreign language to each other, and stated she only speaks English and does not know what they are saying and that they could be talking about her. A CNA interviewed stated staff should not be speaking a different language with each other that is different from the one the resident speaks. The facility’s Resident Rights policy, reviewed 6/2/25, stated employees shall treat all residents with kindness, respect, and dignity and support residents in exercising their rights, including the right to be treated with respect.
Failure to Implement Wandering Care Plan Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to follow an established care plan for a resident identified as being at risk for wandering and elopement, which resulted in an elopement incident. The resident had multiple diagnoses, including encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, and anemia, and the History and Physical documented that the resident did not have the capacity to understand and make decisions. An MDS assessment indicated short- and long-term memory problems, with the resident requiring varying levels of assistance for ADLs. An Elopement Risk Evaluation dated 3/8/26 identified the resident as at risk for elopement, with comments specifying use of a Wanderguard and frequent visual checks. A wandering risk care plan initiated the same day included interventions such as a bracelet alarm for alarmed doors, checking the resident’s location every 30 minutes, and ensuring all staff were aware of the elopement risk. Despite these identified risks and care plan interventions, the facility did not implement the ordered Wanderguard or ensure monitoring consistent with the care plan prior to the elopement. A registered nurse supervisor reported receiving a physician’s order for a Wanderguard and, because the resident could not consent, contacting the resident representative for consent and endorsing follow-up to the next shift. Progress notes for the following day showed no evidence that any shift followed up on obtaining consent or implementing the Wanderguard before the resident eloped in the early morning hours of 3/10/26. A LVN confirmed that there was no order in the order summary for monitoring a Wanderguard or wandering behaviors through 3/17/26, and therefore no related documentation or monitoring occurred. The facility’s own wandering and elopement policy stated that residents at risk would have care plans including strategies and interventions to maintain safety, but the documented interventions were not carried out for this resident.
Improper Linen Handling and Storage Breaching Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to handle and store clean linen in accordance with its infection prevention and control policies and its in-service training on proper linen handling. An anonymous complaint was received alleging insufficient linen and blankets. During review of an in-service titled “Proper handling of Linen,” the facility’s guidance stated that clean linen should be stored in a designated clean area or cart, kept covered when transported to a patient room, and that only the amount of linen needed for each resident should be brought to the room. The sign-in sheet for this in-service did not include the name of CNA 1. The facility’s Laundry and Linen policy required separation of soiled and clean linen at all times and protection of clean linen from environmental contamination by covering clean linen carts. During observation and interview in a resident room, surveyors noted a large, open plastic bag filled with multiple bed pads, gowns, towels, and sheets placed on the nightstand next to the bed of a female resident with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, DM, metabolic encephalopathy, CKD stage 4, dementia, muscle weakness, and polyneuropathies. This resident’s MDS showed impaired cognition and total dependence on staff for toileting, showering, bathing, and transfers. CNA 1 stated that the resident had already received a bed bath and explained that she gathered all linen for all of her residents in the morning, placed it in one bag, brought that bag into this resident’s room, and then used that bag as a source of linen for other residents by transferring items into separate plastic bags. CNA 1 stated this was common practice. Another CNA reported gathering linen for each resident separately and placing each bag in the respective resident’s closet for infection control. An LVN stated CNAs were educated to gather linens in a plastic bag and place them inside each resident’s room so each resident would have their own separate bag, and acknowledged that having all linen for every resident in one room could lead to cross contamination because once linen is taken into a room it is considered dirty. Additionally, on a separate floor, two linen carts were observed with their covers flipped up, leaving clean linen exposed, contrary to the facility’s policy to keep clean linen hygienically clean and protected from environmental contamination.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake. Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN. Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents. Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff. The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions. These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.
Failure to Notify Physician After Repeated Refusal of Vital Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors by not notifying the physician after repeated refusals of vital psychotropic medications. The resident had documented diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse, medical noncompliance, and severely impaired cognition. Multiple clinical documents, including the history and physical, psychiatry evaluations, and physician progress notes, indicated the resident lacked capacity to make medical decisions, had a history of refusing care, and was being treated with Depakote for bipolar disorder and risperidone for paranoid schizophrenia. Review of the resident’s care plan showed a problem for altered behavior patterns related to schizophrenia and psychotropic medication use, with an intervention to notify the physician of any risk or consequences related to non-compliance. The physician’s orders included Depakote 500 mg, two tablets at bedtime for bipolar disorder, and risperidone 3 mg every 12 hours for paranoid schizophrenia. Review of the Medication Administration Record for the month showed that Depakote doses were refused on nine occasions and risperidone doses were refused multiple times for both morning and evening administrations over the review period, including several instances of refusals on three or more consecutive days. Interviews with an LVN and the DON confirmed that facility policy titled “Preparation and General Guidelines” required physician notification when consecutive doses of a vital medication were refused, and that nursing staff were to document the notification and the physician’s response. The LVN stated that if the resident refused Depakote and risperidone for at least three consecutive days, the physician should be notified and the response documented. The DON, upon review of nursing progress notes for the same period, stated that there was no documentation showing that a physician had been notified about the resident’s repeated refusals of Depakote and risperidone. The DON further acknowledged that without such notification, the physician would assume medications were being administered and would not know what other interventions to order, confirming that the required notification and documentation did not occur.
Missed Dialysis Treatments Due to Failed Transportation Arrangements
Penalty
Summary
The deficiency involves the facility’s failure to ensure reliable transportation for a resident who required thrice-weekly hemodialysis, resulting in multiple missed treatments. The resident had diagnoses including pulmonary hypertension, type 2 diabetes mellitus, end stage renal disease with dependence on renal dialysis, and required assistance with transfers. Physician orders specified dialysis on Tuesday, Thursday, and Saturday with set chair times and transportation pick-up and return times. The care plan documented that the resident missed dialysis appointments on two occasions due to transportation issues, and progress notes and SBAR forms showed that on three separate dates the resident missed scheduled dialysis because transportation either did not arrive or would arrive too late for the appointment. On at least one occasion, the missed dialysis was attributed to an expired Physician Certification Statement (PCS) form that had not been timely completed and signed by the primary physician, which was required by the resident’s insurance to authorize transportation. Interviews with staff further described the actions and inactions that led to the deficiency. The social services director stated that one missed dialysis treatment occurred because the PCS form had expired and was not completed in a timely manner by the primary physician, and that other missed treatments were due to the contracted insurance transportation not showing up on time. The social services director acknowledged that the resident’s insurance provided transportation based on the PCS certification. The RN supervisor confirmed awareness of at least one missed dialysis treatment and explained that RNs and LVNs process physician orders and work with social services for transportation, noting that some transportation companies fail to show up without warning. The DON stated that the resident had missed a dialysis treatment because transportation did not show. Facility policies on Transportation and Appointments indicated that social services would help residents obtain transportation and that the facility would assist in scheduling appointments and arranging necessary transportation, but the documented events show that these processes did not prevent the resident from missing multiple medically necessary dialysis sessions.
Failure to Provide Required SOC and Coverage Notices to Resident and POA
Penalty
Summary
The facility failed to provide required written notice of Medicaid/Medicare coverage, share of cost (SOC), and related financial obligations to a resident and the resident’s responsible party/POA. The resident, who had diagnoses including aphasia following cerebral infarction, hemiplegia, and hemiparesis, was assessed as having no cognitive impairment on an MDS dated 11/18/2025 and reported that their son was the responsible party/POA. The resident stated that while in the facility they were not provided any financial documents and no one from the facility discussed monthly billing for services. About a week prior to the interview, the resident learned from the responsible party/POA that payments were behind for the past four months. The social services director reported that due to ownership changes and high turnover in the business office and social services staff during 2025, some residents’ records had not been updated and some residents with SOC had not yet been notified, even though the business office was responsible for updating and notifying residents and responsible parties. The business office manager stated that residents with SOC are usually identified at pre‑admission, admission, and periodically, and that Resident 2’s responsible party/POA should have received monthly statements and paid the SOC that began in September 2025. However, the business office manager could not verify whether monthly statements or SOC notifications had been mailed to the resident or responsible party and acknowledged that past‑due bill notifications should come from the business office, not from a third‑party company. The responsible party/POA confirmed not receiving monthly statements, not knowing the SOC amount, and only becoming aware of four months of past‑due bills after a collection call from a third‑party company. The facility’s billing policy required monthly resident billing with itemized non‑covered services and written notification at least 60 days prior to changes in the cost of non‑covered items and services.
Failure to Perform Hand Hygiene Before Resident Feeding
Penalty
Summary
Facility staff failed to perform required hand hygiene while providing care to one of seven sampled residents, resulting in a deficiency in the infection prevention and control program. During a tour, CNA 3 was observed assisting a resident in a shared room by using the bed remote, placing the remote on the floor, then picking it up and placing it on the resident’s bed without cleaning it. CNA 3 then proceeded to feed the resident without performing hand hygiene. In a concurrent interview, CNA 3 acknowledged not performing hand hygiene and stated that infection prevention and hand hygiene are important because they prevent residents from harm. In the same room, CNA 4 was observed entering from the hallway and approaching to feed the same resident without performing hand hygiene. In a concurrent interview, CNA 4 acknowledged not practicing hand hygiene and stated that hand hygiene is very important to keep residents safe because they are weak and can easily get sick. Record review showed the resident had diagnoses including anoxic brain damage, UTI, a disorder involving the immune mechanism, and heart failure, and was cognitively impaired and dependent on staff for substantial/maximal assistance with eating and personal hygiene. The ADON stated that all staff are trained and expected to perform hand hygiene before and after resident care, and the IP stated that hand hygiene is a standard precaution and agreed that staff were supposed to perform hand hygiene before feeding a resident. The facility’s Infection Prevention and Control Program policy indicated that infection prevention includes educating staff and ensuring adherence to proper techniques and following CDC guidelines.
Failure to Develop Discharge Care Plans for Three Cognitively Intact Residents
Penalty
Summary
The facility failed to develop discharge care plans for three sampled residents, despite facility policy that discharge planning begins at admission and should be updated after discharge meetings and every three months. Interview and record review showed that Residents 1, 2, and 3, all with intact cognition, did not have discharge care plans in their medical records. The medical record assistant confirmed that no discharge care plans were found for these residents, and the director of social services stated that discharge planning is expected to start at admission. Resident 1, an older female admitted with a left humerus fracture, generalized muscle weakness, encephalopathy, cystitis, bilateral knee osteoarthritis, anxiety, hypertension, major depressive disorder, and repeated falls, was documented as dependent for toileting, bathing, and transfers. Resident 2, an older female with osteoarthritis of the knee, morbid obesity, dysphagia, schizoaffective disorder, bipolar disorder, and glaucoma, was also dependent for toileting, bathing, and transfers. Resident 3, an older female with spinal stenosis, fibromyalgia, knee osteoarthritis, diabetes mellitus, morbid obesity, anxiety, insomnia, GERD, and major depressive disorder, required maximal assistance with toileting, bathing, and transfers. Despite these documented care needs and intact cognition, no discharge care plans were developed for any of the three residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving two residents to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's own Abuse Investigation and Reporting policy. The incident occurred when one resident alleged that another resident hit him on the leg, and law enforcement was called to the facility. The facility became aware of the abuse allegation at approximately 5:30 AM, but the report to the state survey agency was not made until 9:09 AM, exceeding the mandated two-hour reporting window. Interviews with staff confirmed awareness of the reporting requirement and acknowledged the delay in notification. The resident who made the allegation had a history of heart failure, diabetes mellitus, and cystitis, and was dependent on staff for personal care, with intact cognitive ability. The other resident involved had diagnoses including a left thigh fracture, heart failure, and diabetes mellitus. The facility's policy required immediate reporting of abuse allegations, especially those involving abuse or resulting in serious bodily injury, but this protocol was not followed in this instance, as evidenced by the delayed fax confirmation of the report.
Failure to Provide Social Services After Abuse Allegations
Penalty
Summary
The facility failed to provide medically-related social services to four out of six sampled residents by not ensuring the Social Services Director (SSD) assessed the residents' psychosocial well-being after incidents involving physical and/or verbal abuse allegations. Specifically, after one resident alleged being hit by another and law enforcement was called, there was no documented follow-up or assessment by the SSD for either resident involved. In another incident, two residents exchanged verbal abuse in the activity room, witnessed by staff, but again, there was no documented psychosocial assessment or intervention by the SSD for those involved. Additionally, a resident reported being hit on the wrist by a roommate and stated that the SSD did not come to speak with him about his feelings, despite expressing a desire for such support. Interviews with the SSD confirmed that follow-up was not conducted with several residents involved in these incidents, and in one case, although the SSD claimed to have followed up with a resident, there was no documentation of these interactions. The facility's own policies and job descriptions require the SSD to address and document the psychosocial needs of residents, particularly following abuse allegations. The lack of timely and documented follow-up by the SSD after abuse allegations meant that the psychosocial needs of the affected residents were not assessed or addressed as required. This failure was acknowledged by both the SSD and the facility's nurse consultant, who stated that such follow-up is necessary to identify and meet residents' psychosocial needs. The omission was contrary to facility policy and the expectations outlined in the social worker's job description.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were answered in a timely manner, as required by facility policy. Resident 4, who had systemic lupus erythematosus, pain from orthopedic devices, generalized muscle weakness, and partial traumatic amputation of both feet, was dependent on staff for mobility and toileting. Resident 4 reported that it often took twenty to thirty minutes for staff to respond to call lights, resulting in prolonged periods of being wet and soiled, which exacerbated pain and discomfort. Resident 4 stated that despite raising concerns with staff, the issue persisted. Resident 5, diagnosed with cardiomyopathy, hypertension, and anxiety disorder, was also dependent on staff for transfers and mobility. Resident 5 reported frequent delays in call light response, particularly at night, and expressed feelings of neglect after complaints to the night shift charge nurse did not resolve the issue. Interviews with CNAs confirmed that residents commonly complained about delayed call light responses, especially during shift changes or when staffing was reduced due to call-outs. The DON acknowledged that facility policy required immediate or prompt response to call lights, and that call lights were the primary means for residents to request assistance.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to adequately supervise and monitor the whereabouts of a resident who was admitted with significant psychiatric diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, and a recent history of hearing voices instructing self-harm. Upon admission, the resident was identified as being at risk for elopement, and behavioral monitoring was indicated as a primary focus. Despite these risk factors, the resident was able to leave the facility without notifying staff, and their whereabouts remained unknown following the incident. Record reviews revealed inconsistencies and incomplete documentation regarding the resident's expressed desire to leave against medical advice (AMA). Although the resident signed an AMA form, it was missing a date and staff witness signatures, and the physician order summary did not indicate a discharge. Staff interviews indicated that the resident had previously expressed a wish to leave, but was convinced to stay, leading to the incomplete processing of the AMA form. On the day of the incident, staff discovered the resident missing during routine rounds, and subsequent searches and notifications were made to authorities and facility leadership. Observations during the survey found that staff were not consistently monitoring resident whereabouts, particularly during shift changes. No staff were observed making rounds or present at key monitoring locations such as nurses' stations, and certain facility areas, such as a service elevator, were not visible from staff workstations. Staff interviews confirmed that resident accountability was not ensured during shift changes, increasing the risk of elopement for residents identified as high risk.
Failure to Report and Address Nonfunctioning Thermostats and Temperature Regulation
Penalty
Summary
Facility maintenance failed to report nonfunctioning thermostats to administration for three sampled residents, resulting in the air conditioning unit being turned off at night due to an inability to regulate building temperatures. This led to resident complaints about excessive heat during nighttime hours. Observations and interviews confirmed that maintenance staff routinely turned the HVAC system on and off from the roof, as there were no functioning thermostats to regulate temperature, and staff were unaware of the last time the HVAC system was serviced. Maintenance staff also did not inform administration about the nonfunctioning thermostats or the ongoing temperature regulation issues. Residents affected by this deficiency included individuals with significant medical conditions such as peripheral neuropathy, migraines, obesity, cardiovascular disease, stroke with hemiplegia, major depressive disorder, anxiety, hypotension, COPD, spinal stenosis, fibromyalgia, osteoarthritis, diabetes mellitus, morbid obesity, cellulitis, insomnia, GERD, hypertension, and nicotine dependence. Some residents required maximal assistance with activities of daily living and had impaired cognition, while others were dependent on staff for toileting and bathing. Multiple residents reported discomfort due to heat at night, and observations confirmed that fans in resident rooms were not always functional or circulating air. Despite the presence of 55 portable air conditioning units in storage, maintenance staff did not offer these units to residents who complained about the heat, nor did they notify administration of the temperature control issues. Facility policy required that all temperature complaints and malfunctions be reported to administration and documented, but this process was not followed. The maintenance supervisor and assistant were aware of the portable units but did not distribute them or escalate the issue, resulting in continued resident discomfort and noncompliance with facility policy regarding temperature regulation.
Residents Subjected to Forced Removal from Power Wheelchairs and Loss of Mobility Rights
Penalty
Summary
The facility failed to protect two residents from mental and physical abuse when unidentified corporate staff forcefully removed them from their motorized power wheelchairs (MPWC) and placed them into manual wheelchairs (MWC) against their wishes and without clinical justification or consent. The incident involved multiple staff members, including corporate representatives, who attempted to physically transfer the residents despite their verbal refusals and distress. The residents were not provided with an opportunity to speak with law enforcement when the police were called, and their autonomy and right to make decisions regarding their mobility devices were disregarded. One resident, with a history of multiple medical conditions including cellulitis, pressure injuries, chronic pain, and dependence on a wheelchair, was subjected to forceful attempts to remove her from her MPWC. She repeatedly expressed her desire to keep her MPWC and asked to speak with familiar staff or her physician, but was ignored. During the incident, several staff members physically attempted to remove her from the chair, causing her emotional distress and pain in her left arm and shoulder. She was left in a manual wheelchair and confined to bed for an extended period, resulting in psychosocial harm such as anxiety, helplessness, and emotional distress. She was later transferred to a hospital for evaluation of shoulder pain. Another resident, diagnosed with multiple sclerosis, Parkinson's disease, and other conditions leading to dependence on a wheelchair, was also removed from her MPWC by a group of unfamiliar staff. She was transferred to bed using a Hoyer lift and left without her preferred mobility device for several days, which led to her remaining in bed, crying, and experiencing a loss of independence. Both residents' care plans indicated their dependence on MPWCs for mobility and participation in activities, yet these were disregarded by the staff involved. The actions taken by the facility staff resulted in both residents experiencing a loss of autonomy, dignity, and independence, as well as significant psychosocial harm.
Failure to Maintain Audible Phone Ringing at Nursing Stations
Penalty
Summary
The facility failed to maintain the nursing station phone ringers at an audible volume across all four nursing stations, as observed during multiple call attempts. When calls were transferred from the main facility phone line to each nursing station, the phones did not ring audibly at the stations, and staff only became aware of incoming calls after hearing overhead pages instructing them to answer the phone. Interviews with LVNs at each station confirmed that the phone volumes were turned down all the way, preventing them from hearing the phones ring. Staff acknowledged the importance of having the phone volume set at an audible level to ensure calls from doctors, family members, and patients could be answered promptly. A review of the facility's policy and procedures regarding telephone usage indicated that employees should exercise thoughtfulness and courtesy in using telephones and that staff should not be paged to the phone unless it is an emergency. Despite this policy, the phones at all nursing stations were not set to ring audibly, resulting in reliance on overhead paging to alert staff to incoming calls. This practice had the potential to limit or delay communication with medical professionals, family members, and staff.
Failure to Ensure Timely IV Fluid Administration
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care according to its own policies and procedures for one resident. The resident, who had multiple diagnoses including hypertension, diabetes mellitus type 2, muscle weakness, gait abnormalities, heart failure, and asthma, was admitted with an order for Dextrose 5% IV solution to be infused at 50 ml per hour over 20 hours for hydration. On observation, the IV bag was found hanging with approximately 550 ml remaining, not infusing, and the bag was dated two days prior. The IV was connected to the resident's right forearm, but no drops were observed in the drip chamber, indicating the infusion was not running as ordered. A family member reported that the IV had not been infusing for at least 40 minutes and mentioned previous issues with the IV tubing. The Registered Nurse Supervisor was unaware of the IV order and had to check the resident's chart to confirm the order. Upon further interview, the nurse acknowledged forgetting about the IV order despite being informed by the prior shift. The facility's policy requires licensed nurses to be knowledgeable about the length of time needed to administer IV medications, to assess the IV site and system, and to review provider orders for correct administration, all of which were not followed in this instance.
Failure to Explain and Obtain Signature for Admission Agreement at Admission
Penalty
Summary
The facility failed to explain and obtain a signature for the admission agreement at the time of admission for one resident, as required by its policy and procedures. The resident, an elderly female with multiple complex medical conditions including ventricular fibrillation, morbid obesity, diabetes, asthma, congestive heart failure, vascular dementia, and a pressure ulcer, was admitted without the proper completion of the admission agreement. The Minimum Data Set assessment indicated that the resident did not have intact cognition and was dependent on staff for toileting, personal hygiene, and transfers. Documentation and interviews revealed that the resident's family member did not receive the admission packet until several weeks after admission, despite being present at the facility daily. The family member sent questions regarding the admission agreement via email, but did not receive timely responses from the admissions coordinators. The facility's policy requires that the admission agreement, which outlines covered and non-covered services and payment responsibilities, be explained and signed at admission, but this process was not followed, resulting in a lack of clarity regarding the services provided and covered by the facility versus the resident's insurance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of a resident-to-resident altercation involving two residents. One resident, who had intact cognitive skills and required moderate assistance with activities of daily living, reported that another resident, who had moderately impaired cognition and a high risk of wandering, entered his room, sat on his bed, and opened his drawer. The first resident became upset and threw water at the second resident in the hallway. Progress notes documented the incident, and staff indicated they would continue to monitor the second resident's behavior. Despite the documentation of the incident, the facility did not investigate or report the event to the appropriate authorities, including the State, Local Ombudsman, or Police, as required by facility policy and federal regulations. Both the RN and DON acknowledged during interviews that the incident should have been reported and investigated, but no such actions were taken. The facility's policy mandates the identification, investigation, and timely reporting of all possible incidents of abuse, neglect, or misappropriation of resident property, which was not followed in this case.
Failure to Ensure Proper Use of BiPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a diagnosis of obstructive sleep apnea, type II diabetes mellitus, and asthma. The resident was admitted with a physician's order for a BiPAP machine to be used nightly from 9 p.m. until the resident woke up, or as needed, with supplemental oxygen as ordered. Record review showed that the resident was severely cognitively impaired and required total staff assistance for activities of daily living. The care plan included the use of the BiPAP machine during sleep to maintain normal breathing and prevent complications related to shortness of breath. However, the BiPAP compliance report indicated the resident's average usage was only 2 hours and 16 minutes per night, significantly less than the prescribed duration. Interviews with nursing staff and the DON revealed that the BiPAP machine was frequently leaking and alarming at night, indicating it was not properly set or functioning while on the resident. The night shift nurses were reportedly informed to ensure the BiPAP was properly set, but the issue persisted. The DON stated that nurses should be competent in operating and troubleshooting the BiPAP machine, and the physician confirmed that the resident was not receiving the intended therapy duration. Facility policy required documentation of therapy duration, resident tolerance, and physician notification if the resident refused or experienced adverse consequences, but the report did not indicate these steps were consistently followed.
Failure to Ensure Competency and Timely Response by Nursing Staff
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies in caring for residents, resulting in several deficiencies. One resident, a female with multiple complex diagnoses including metabolic encephalopathy, COPD, diabetes, morbid obesity, paraplegia, and other chronic conditions, was observed to have her call light out of reach and left on for an extended period without response. The resident reported being left in an uncomfortable position for about 30 minutes, experiencing significant back pain, and expressed dissatisfaction with a registry CNA who was unfamiliar with her care needs and did not follow her preferences. The call light panel in her room was also found to be hanging out of the wall with exposed wires, though still functional. Staff members, including CNAs, were observed not wearing ID badges, and some were unfamiliar with the residents or the facility's procedures due to infrequent assignments and lack of orientation or huddles at the start of their shifts. Another resident, also with multiple chronic conditions such as spinal stenosis, COPD, morbid obesity, and congestive heart failure, reported a negative experience with a registry CNA who took an extended break, delayed meal service, and failed to complete required showers. The resident felt unsafe during care and noted communication barriers with some registry CNAs who did not speak or understand English well enough to meet her needs. The staffer confirmed that the registry CNA was not familiar with the resident's preferences and was subsequently marked as 'do not return' based on the resident's complaints. Record reviews revealed that competency checklists for registry CNAs were incomplete or missing, with most only documenting competency in resident transfers and lacking evidence of skills in other required areas. The facility had no Director of Staff Development (DSD) to oversee training, and the infection prevention nurse, who had been covering some training duties, had not provided competency training for registry staff. The facility's policy required all nursing staff to demonstrate competency in a range of skills, but there was no evidence that this was consistently ensured for registry CNAs.
Failure to Provide Timely Physical Therapy Evaluations
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) evaluations, for six out of seven sampled residents who had physician orders for PT evaluation and treatment. Despite documented medical needs such as hemiplegia, hemiparesis, recent amputations, vertebral fractures, and other mobility-impairing conditions, these residents did not receive timely PT assessments upon admission. The absence of a licensed PT on staff led to delays, with the facility relying on agency PTs who were only available on an as-needed basis, rather than consistently present to perform required evaluations. Multiple interviews with staff, including the acting director of rehabilitation (a certified occupational therapy assistant), confirmed that PT evaluations were difficult to obtain due to the lack of an in-house PT. The COTA stated they could not perform PT evaluations and that agency PTs were only intermittently available. Residents and family members reported concerns, including one resident who did not receive assistance with prosthetic legs and another whose back brace was not properly applied for several days due to lack of PT involvement. These issues were corroborated by the Ombudsman and family interviews, which highlighted the residents' unmet rehabilitative needs and dissatisfaction with the care provided. Record reviews showed that all six residents had physician orders for PT evaluation and treatment, but these were not fulfilled in a timely manner. Facility policy required that specialized rehabilitative services be provided by qualified personnel upon physician order, but the lack of a consistent PT presence resulted in noncompliance with this policy. The deficiency placed residents at risk of a decline in mobility and failure to address their rehabilitative needs as ordered by their physicians.
Failure to Provide Consistent Dining Room Access for Dinner
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice by not consistently opening the dining room for dinner to all residents every day. Interviews with staff, including the activity director (AD) and restorative nursing assistant (RNA), revealed that while the dining room was regularly open for lunch, it was not always available for dinner. The AD stated that since their employment, residents typically ate breakfast and dinner in their rooms, and the dining room was only used for lunch. The RNA confirmed that the dining room operated from 9:00 a.m. to 4:00 p.m., with no clear information about dinner service. The director of nursing (DON) initially believed the dining room was open for all meals but later learned from the AD that staffing shortages prevented consistent dinner service in the dining room. A review of a specific resident's records showed that the resident, who had intact cognition and was independent with eating and mobility using a manual wheelchair, normally ate dinner in his room due to the lack of staff to facilitate dinner in the dining room. The resident indicated that this issue had been previously discussed with facility administration but was never resolved. Facility policies reviewed stated that all residents should be encouraged to eat in the dining room and that staff should assist those who require help with meals, emphasizing dignity and respect. The facility's own policies on resident rights and meal assistance highlighted the importance of supporting resident choice and providing a dignified dining experience. However, the practice of not opening the dining room for dinner to all residents every day was found to be inconsistent with these policies and constituted a violation of residents' rights to self-determination and choice regarding their dining preferences.
Insufficient Staffing Limits Dining Room Access for Meals
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the dining room was open and available to residents for all meals, as required. Observations and interviews revealed that residents were only able to eat in the dining room for lunch, while breakfast and dinner were typically served in residents' rooms. The activity director confirmed that since their employment, the dining room had only been used for lunch, and was unaware of the reason for this practice. The restorative nursing assistant also stated that the dining room opened at 9:00 a.m. and closed at 4:00 p.m., with breakfast being served in residents' rooms and uncertainty about dinner service due to their shift ending before dinner time. Staffing records and interviews indicated significant staffing challenges, including multiple certified nursing assistants calling off and being replaced by registry staff or other personnel. The director of nursing initially stated that residents could eat in the dining room for any meal, but later acknowledged, after speaking with the activity director, that the dining room was not always open for dinner due to insufficient staff to monitor residents during meals. This lack of staffing directly impacted residents' ability to exercise their right to dine in the dining room at all mealtimes. A resident with a history of hemiplegia, hemiparesis, stroke, and other medical conditions reported that he normally ate dinner in his room because there was not enough staff to facilitate dinner in the dining room. This issue had been previously discussed with the former administrator but remained unresolved. The facility's own policy stated that staffing levels should be based on resident needs and care plans, and that support services should be adequately staffed to meet those needs, which was not met in this instance.
Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of an alleged staff-to-resident abuse incident. A resident with severe cognitive impairment and significant physical disabilities was the subject of an allegation that a CNA was rough during ADL care and pushed the resident from the bed. The allegation was initially reported by the resident's roommate, who stated she informed the nursing staff, but observed that the CNA continued to work on the same floor throughout the week. Interviews with staff confirmed that the CNA was separated from the residents involved but was not suspended and continued working in the facility. Documentation review revealed that the incident was not reported to all required agencies, including the district office, Ombudsman, physician, family, and police, as mandated by facility policy. The SBAR documentation completed by the RN did not fully reflect the details of the allegation as reported by the resident, and the investigation findings were not submitted within the required five-day period. The DON confirmed that all abuse allegations should be reported and investigated according to policy, but there was no evidence that this was done in this case. The facility's written policy requires immediate reporting of abuse allegations within two hours if abuse or serious bodily injury is involved, and a written report of the investigation findings within five working days. In this instance, the facility did not adhere to these requirements, resulting in a delay in the Department of Public Health's onsite inspection and potentially delaying the prevention of further abuse for the resident involved.
Failure to Provide Physical Therapy Services Due to Lack of PT Staff
Penalty
Summary
The facility failed to employ a full-time Physical Therapist (PT) to provide specialized rehabilitative services to its 144-bed capacity, resulting in the absence of PT services for residents who may require evaluation and treatment. At the time of the survey, there were no PT staff working in the facility, as the previous PT had resigned approximately two weeks prior. Interviews with the Occupational Therapist and the Director of Nursing confirmed that there were about nine residents with current physician orders for physical therapy who were not receiving these services. Review of the facility's policy indicated that specialized rehabilitative services, including physical therapy, are to be provided by qualified professional personnel as indicated by resident assessments.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. The Social Services Director (SSD), who met the qualifications, had not been present in the facility since February due to a family emergency. In the absence of the SSD, the Social Service Assistant (SSA), who does not possess the required educational background or supervised social work experience, assumed the roles and responsibilities of the SSD. Review of the SSA's employee file confirmed the lack of necessary qualifications. During this period, a resident with multiple diagnoses, including osteoarthritis, asthma, and spinal stenosis, and who required significant assistance with activities of daily living, reported not having met with the SSD since readmission. The resident had only interacted with the SSA regarding non-clinical concerns and had not participated in a care plan meeting. The facility's policy requires a qualified social worker to provide medically-related social services to support residents' well-being, but this standard was not met due to the absence of a qualified SSD.
Failure to Promptly Respond to Resident Call Light
Penalty
Summary
A deficiency occurred when staff failed to promptly respond to a resident's call light. The resident, who had diagnoses including type II diabetes mellitus, fibromyalgia, and chronic kidney disease, required maximal to total assistance with activities of daily living and was assessed as cognitively intact. The resident's care plan included an intervention to ensure the call light was within reach and to encourage its use for assistance. During an observation, the call light was seen blinking outside the resident's room and the alarm was audible at the nursing station. The resident reported having pressed the call light over 30 minutes prior and was waiting for help to put on underpants, remaining in only an incontinent brief during this time. Staff interviews revealed that the LVN responded to the call light after the extended wait and then sought out a CNA to assist the resident, as the CNA was occupied with another resident. Both the LVN and the DON confirmed that call lights should be answered immediately by any available staff, and the facility's policy required call lights to be answered immediately, with requests fulfilled within five minutes if possible. The failure to respond promptly to the call light resulted in the resident not receiving timely assistance for personal care needs.
Single-Staff Mechanical Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a shower chair to bed using a mechanical Hoyer lift without the required assistance of a second staff member. The resident involved had diagnoses including congestive heart failure, depressive disorder, and age-related osteoporosis, and was assessed as totally dependent on staff for activities of daily living. The resident's care plan specified the use of a Hoyer lift for transfers due to limited physical mobility, and the facility's policy required at least two nursing assistants for safe operation of the mechanical lift. During observation, the CNA was seen performing the transfer alone, and later confirmed in an interview that he believed it was permissible to use the Hoyer lift with only one person. However, both a licensed vocational nurse (LVN) and the director of nursing (DON) stated that two staff members are required for such transfers to ensure resident safety. Review of facility policy further confirmed this requirement. The failure to follow established procedures placed the resident at risk during the transfer.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's Abuse Investigation and Reporting policy. The incident involved a resident with a history of metabolic encephalopathy, COPD, and heart failure, who was assessed as having moderate cognitive impairment and required assistance with activities of daily living. The alleged verbal abuse occurred during an overnight shift when a CNA was reported to have called the resident 'crazy' after the resident became upset about being woken for incontinence care. Documentation showed that the incident was noted in the resident's progress notes and care plan, and staff statements confirmed that the allegation was communicated to supervisory staff. However, the report to the Department of Public Health was not made until several hours after the incident, well beyond the two-hour requirement. The delay was attributed to a busy shift and a misunderstanding about which shift was responsible for making the notification. Interviews with staff, including the CNA, LVN, RN supervisor, and the administrator, confirmed the timeline of events and the failure to report the allegation promptly. The facility's policy clearly required immediate reporting of abuse allegations, but this protocol was not followed, resulting in a delay in notifying the appropriate authorities about the alleged verbal abuse.
Failure to Prevent and Intervene in Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to develop and implement interventions to prevent ongoing verbal abuse between two residents sharing a room. One resident, who was dependent on staff for toileting, showering, and transfers due to multiple medical conditions including bilateral osteoarthritis, anemia, and hypertension, reported repeated incidents of verbal abuse and controlling behavior by her roommate. These incidents included the roommate pushing her bed, blocking the door with a wheelchair or walker, making derogatory remarks, and dictating the use of lights and television in the room. The affected resident expressed fear and distress, stating that she had reported these issues to staff but saw no changes. Staff interviews and record reviews confirmed that the roommate frequently blocked the door, used offensive language, and created a hostile environment. A certified nursing assistant (CNA) witnessed the roommate obstructing access to the room and making derogatory comments, and reported these incidents to the director of staff development (DSD). However, there was no evidence that effective interventions were put in place to address or stop the abusive behavior. The social service assistant (SSA) and registered nurse (RN) both documented ongoing conflicts between the residents, with both refusing room changes, but no further follow-up or resolution was documented after grievances were filed. Despite multiple reports and observations of the abusive interactions, facility leadership, including the DSD, regional director, and administrator, were either unaware of the extent of the verbal abuse or did not take further action beyond offering room changes. The facility's own policy required prompt investigation and intervention in cases of alleged abuse, but the lack of follow-up and failure to implement protective measures left the resident at continued risk for verbal abuse.
Failure to Develop Care Plan for Resident with Liver Transplant
Penalty
Summary
The facility failed to develop a care plan addressing a resident's history of liver transplant. Review of the resident's admission record showed multiple complex diagnoses, including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, kidney transplant, and liver transplant. The resident was noted to be cognitively intact but required varying levels of assistance with activities of daily living. Despite these complexities, there was no care plan specific to the liver transplant documented in the resident's records. During an interview and record review with the DON, it was confirmed that a care plan for the liver transplant was missing, and the DON acknowledged that such a plan should have been in place to guide staff in providing appropriate care. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not followed for the resident with a liver transplant.
Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure that services met professional standards of quality by not properly communicating a resident's high risk for elopement and by not ensuring the resident wore an identification (ID) wristband. A resident with significant cognitive impairment, including diagnoses of parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was admitted with orders for frequent monitoring and the use of a Wanderguard device due to elopement risk. Despite these orders, staff assigned to the resident were not formally notified of the elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the resident's risk status or the purpose of the Wanderguard, as this information was not communicated during shift handoff or morning huddle. Additionally, the resident was observed on multiple occasions without an ID wristband, contrary to facility policy requiring such identification for resident safety and proper administration of care. Staff interviews confirmed that the resident should have had an ID wristband and that the lack of communication regarding the resident's risk status and identification requirements contributed to the deficient practice. Facility policies reviewed indicated the necessity of both the Wanderguard system for elopement risk and the ID wristband for resident identification, but these were not consistently implemented for the resident in question.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care treatment for a resident with a skin tear on the right wrist/hand. The resident, who was admitted with diagnoses including parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was documented as lacking the mental capacity to make medical decisions and was dependent on staff for daily activities. The care plan indicated that skin tears should be treated per facility protocol, and an active physician's order specified cleansing the wound with normal saline, patting dry, applying xeroform, and covering with a dry dressing. During observation, the resident's skin tear was found to be scabbed and open to air without a dressing. The LVN present was unaware if the wound should be covered, stating that a treatment nurse typically performed wound care. The DON later stated that the wound did not need to be covered since it was scabbed, but acknowledged that if there was an order, it should be followed. The facility's wound care policy required following physician's orders and care plans for wound treatment.
Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure proper communication and implementation of safety measures for a resident identified as high risk for elopement. The resident, who had diagnoses including parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was assessed as lacking the mental capacity to make medical decisions and was severely cognitively impaired. Documentation indicated the resident had a history of leaving the facility and was at risk for elopement, with orders in place for frequent monitoring and the use of a Wanderguard device. However, staff assigned to the resident were not formally notified of the resident's elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the purpose of the Wanderguard or the resident's risk status due to lack of communication during shift handoff and morning huddles. Additionally, the resident was observed without an identification wristband on multiple occasions, contrary to facility policy requiring such identification for resident safety. Staff interviews confirmed that the absence of the ID wristband could hinder proper identification and safe care delivery. The facility's policies on Wanderguard use and resident identification were not followed, as evidenced by the lack of communication regarding the resident's risk status and the missing ID wristband, placing the resident at increased risk for elopement and other safety incidents.
Failure to Prevent Repeated Falls and Injuries in High-Risk Resident
Penalty
Summary
The facility failed to ensure a resident at risk for falls was adequately supervised and monitored, resulting in repeated falls and injuries. Despite being identified as a fall risk due to a history of falls, dementia, muscle wasting, and unsteady gait, the resident experienced three separate falls over a six-month period. The care plan, titled 'Falling Star Program,' included interventions such as keeping the bed in the lowest position, locking wheelchair wheels, maintaining a clutter-free environment, and using non-skid footwear. However, these interventions were not consistently implemented or revised after each fall, and the effectiveness of the care plan was not evaluated following subsequent incidents. After each fall, documentation showed that the interdisciplinary team (IDT) and staff did not adequately address or update interventions to prevent future falls. For example, after the resident was found on the floor with injuries, the care plan was not revised to include more intensive supervision or additional safety measures. The facility also failed to ensure the resident's environment was free from hazards, as evidenced by an incident where the resident slipped on a puddle of urine by the bedside, leading to a severe hip fracture that required surgical intervention. Observations further revealed that the resident's call light was not within reach, and the resident was seen attempting to get out of bed unsupervised, stepping on a wet floor mat. Interviews with staff confirmed lapses in supervision and environmental safety. The DON acknowledged that the resident should have been placed on one-to-one care with a sitter, as outlined in the care plan, but this was not done. Additionally, staff failed to follow the facility's own policies and procedures regarding fall risk management, which required re-evaluation and modification of interventions after each fall. These failures directly contributed to the resident's repeated falls and resulting injuries.
Failure to Notify Physician and Document Change of Condition
Penalty
Summary
Facility staff failed to notify the physician when a resident experienced a change of condition, specifically after the resident complained of a sore throat, swallowing issues, and body itching. The resident, who had diagnoses including congestive heart failure, diabetes mellitus, and dementia with severely impaired cognitive skills, was admitted to the facility and later tested positive for Pertussis. Despite the resident's complaints and the family member's request for lab testing, there was no documented evidence that staff recognized or reported these symptoms as a change of condition or incident of concern. Interviews with facility staff, including a registered nurse and the infection preventionist nurse, confirmed that the required documentation and physician notification were not completed when the resident exhibited these symptoms. The facility's policy required prompt notification of the physician and documentation of any changes in a resident's condition, but this protocol was not followed in this instance. The lack of documentation and notification was validated by both the nursing and infection prevention staff during the survey.
Failure to Document and Address Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to document and address grievances according to its policy for one resident. The resident, who was admitted with diagnoses including congestive heart failure, diabetes mellitus, and dementia, had severely impaired cognitive skills and required moderate assistance with activities of daily living. The resident's family member expressed dissatisfaction with the lack of activities provided and the inability to reach department heads or receive timely responses from nursing staff. These concerns were documented in the resident's progress notes by the Social Service Director. Despite these documented concerns, a review of the facility's grievance records for the relevant period showed no completed grievance forms for the resident. During an interview, the Director of Nursing confirmed that there was no documentation of grievances for this resident and acknowledged that the Social Service Director should have assisted the family member in submitting a grievance form, as required by facility policy. The facility's policy states that upon receiving a grievance, an investigation should begin and a grievance report form should be filed within five working days, which was not done in this case.
Failure to Inventory and Return Residents' Personal Belongings
Penalty
Summary
The facility failed to protect the personal belongings of two residents by not properly inventorying and documenting their possessions upon admission and discharge. For one resident with diagnoses including congestive heart failure, diabetes mellitus, and dementia, there was no inventory of personal belongings recorded in the medical record at either admission or discharge. The DON confirmed that staff are required to complete and document an inventory of personal belongings at these times, but this was not done for the resident, who had severely impaired cognitive skills and required moderate assistance with activities of daily living. For another resident with metabolic encephalopathy, malnutrition, and atrial fibrillation, the inventory of personal belongings was incomplete and lacked discharge signatures from the resident or their representative. The record showed that additional items were delivered by family during the stay, but there was no documentation that the belongings were returned to the resident or their representative upon transfer to a general acute care hospital. The DON acknowledged that the facility did not follow its policy to ensure belongings were returned and properly documented, as required by facility procedures.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Upon review, it was found that the resident was admitted with multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia, and required moderate assistance with activities of daily living due to severely impaired cognitive skills. Despite these needs, the initial care plans addressing falls, allergies, pain/discomfort, and skin integrity were not initiated until ten days after admission. The Director of Nursing confirmed that the baseline care plans were not completed within the required 48-hour timeframe, as stipulated by the facility's policy and procedures. The delay in initiating these care plans was verified through interviews and record reviews, which showed that the resident's immediate health and safety needs were not formally addressed in a timely manner following admission.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of four residents by not ensuring that televisions were operational and hot water was consistently available. Residents 4, 5, and 6 reported that their televisions were non-functional for three days, which affected their ability to watch programs and stay updated with current news. Additionally, Residents 4, 5, 6, and 7 experienced issues with hot water availability during showers, with Resident 4 stating that hot water was often unavailable since admission, and Resident 5 having to shower early to avoid running out of hot water. Resident 6 expressed reluctance to shower due to consistently cold water, and Resident 7 reported an inability to shower consistently due to frequent hot water shortages. Interviews with the Maintenance Director and Nursing Consultant revealed that the Maintenance Director was newly hired and still assessing building issues, while the Nursing Consultant acknowledged the facility's responsibility to accommodate residents' needs and preferences. The facility's policy on accommodation of needs emphasized assisting residents in maintaining safe, independent functioning and dignity, and stated that individual needs and preferences should be accommodated to the extent possible. However, the facility's failure to ensure working televisions and consistent hot water supply demonstrated a lack of adherence to this policy, potentially impacting the residents' psychosocial well-being and delaying necessary care.
Resident's Right to Privacy Breached by Receiving Opened Mail
Penalty
Summary
The facility failed to protect a resident's right to privacy by not ensuring that the resident received unopened mail. During an interview and record review, it was found that a resident, who was admitted with conditions including spinal stenosis, obesity, and COPD, received an opened letter addressed to them. The resident expressed feeling uneasy about this breach of privacy, as it is their right to receive unopened mail. The facility's Nursing Consultant confirmed that residents' mail should not be opened, aligning with the facility's California Standard Admission Agreement for Skilled Nursing Facilities, which states that patients have the right to receive unopened personal mail. Additionally, the facility's policy and procedure on Resident Rights and Release of Information emphasize treating residents with respect and maintaining the confidentiality of their personal and protected health information.
Delayed Response to Call Light Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, specifically affecting one resident who experienced a significant delay in response to a call light. Resident 4, who was admitted with a fracture of the right femur and low back pain, had intact cognition and required no assistance for activities of daily living. However, when Resident 4 activated the call light to request ice chips, the response was delayed by over one and a half hours. The facility's policy mandates that call lights should be answered immediately to ensure timely responses to residents' needs. During an interview, the facility's Nursing Consultant confirmed that call lights should be answered without delay. This deficiency in staffing and response time has the potential to affect the quality of life and delay necessary care for residents, as evidenced by the experience of Resident 4.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was appointed by the Governing Board, which had the potential to affect resident care and management of the facility. During a review of the posted licensing information on the facility's consumer bulletin board, it was observed that no administrator license was posted. In an interview, the Acting Administrator (AA) stated that his license was not displayed because he was not appointed by the governing board, as he would exceed the 200-bed limit for supervision. The facility's policy and procedure documents indicated that the administrator should be appointed by and accountable to the governing board, and a licensed administrator is responsible for the day-to-day functions of the facility.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was appointed by the governing board, which is a requirement for managing and operating the facility. During an observation of the facility's consumer bulletin board, it was noted that there was no administrator license posted. In an interview, the Acting Administrator (AA) stated that his license was not posted because he had not been appointed by the governing board, as he would exceed the 200-bed limit for supervision. The facility's policy and procedure documents, reviewed in November 2024, indicated that the administrator should be appointed by and accountable to the governing board and is responsible for the day-to-day functions of the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. Staff were observed placing personal items, such as a Monster energy drink, in the kitchen refrigerator, which could potentially contaminate food meant for residents. This was confirmed by the Dietary Supervisor, who acknowledged the risk of contamination and illness to residents. Additionally, staff did not adhere to hand hygiene protocols. A Certified Nurse Assistant (CNA) was seen handling dirty linen without gloves and failed to perform hand hygiene afterward. Another CNA exited a droplet precaution room without wearing the required N95 mask and gloves, and also did not perform hand hygiene after doffing an isolation gown inappropriately. The Infection Prevention Nurse confirmed that there was no infection control training documented for one of the CNAs, highlighting a gap in staff training and competency. The facility also did not ensure that medical equipment was handled properly. A resident's nasal cannula tubing was found on the floor, and another resident's nebulizer equipment was not covered, posing a risk of contamination. The Director of Nursing acknowledged that these practices could lead to respiratory infections. Furthermore, during an influenza outbreak, staff were observed wearing N95 masks improperly, which could contribute to the spread of infection among residents. The facility's policies on infection control and personal protective equipment were not consistently followed, as evidenced by these observations.
Failure to Maintain Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records of four residents were complete and updated concerning advance directives. This deficiency was identified during interviews and record reviews, where it was found that the facility did not maintain an accurate and current copy of the residents' advance directives in their clinical records. The absence of these documents had the potential to cause conflict with the residents' wishes regarding healthcare, particularly in situations where they were unable to communicate their preferences. Resident 72 was admitted with diagnoses including hypertension, anxiety disorder, and muscle weakness, and was found to have severely impaired cognition. Resident 27, with Type 2 Diabetes Mellitus and hypertension, had moderately impaired cognition but was independent in activities of daily living. Resident 65, diagnosed with anxiety disorder and depression, had severely impaired cognition and required assistance with daily activities. Resident 114, with dementia and Alzheimer's disease, also had severely impaired cognition and required supervision for daily activities. None of these residents had their advance directives documented in their records. Interviews with facility staff, including the Social Services Director and a Licensed Vocational Nurse, revealed that the process for obtaining and documenting advance directives was not consistently followed. The Social Services Director stated that residents or their representatives are asked about advance directives during admission, and if they do not have one, they are offered the opportunity to complete one. However, if they refuse, a form indicating their refusal should be maintained in the chart, which was not done in these cases. The Director of Nursing emphasized the importance of having advance directives in the chart to honor residents' last wishes, but this protocol was not adhered to, leading to the identified deficiency.
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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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