Seal Beach Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seal Beach, California.
- Location
- 3000 N Gate Road, Seal Beach, California 90740
- CMS Provider Number
- 056010
- Inspections on file
- 99
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Seal Beach Health And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with anxiety and depression, who had expressed fear about having another heart attack, returned a meal tray that was not to her liking and received a newly prepared tray from dietary staff. While walking back to the room, the resident and a dietary aide spoke loudly, and the resident called the aide names. When the aide later returned with yogurt, the resident yelled at the aide, who responded by yelling, cursing, and making derogatory comments, including calling the resident "crazy." CNAs overheard the profanity and observed the resident crying and distressed, and documentation showed the resident experienced increased anxiety and brief situational emotional distress related to the altercation.
A resident with anxiety and depression, who was cognitively intact and had expressed fear of another heart attack, experienced increased anxiety and brief emotional distress after a dietary aide yelled at them during meal service. A change in condition evaluation was completed and the care plan was updated to include monitoring every shift for 72 hours for changes in routine and symptoms of distress, consistent with facility policy and staff descriptions of required practice. However, nursing staff did not complete the required follow-up assessments and monitoring after the incident, and the ADON confirmed that the resident was not monitored following the verbal abuse allegation and that all assessments were missed on a subsequent day, a finding verified by the DON.
A resident with a gastrostomy tube experienced multiple episodes of tube dislodgement requiring medical intervention, but the facility did not assess or document the causes of these incidents, nor did it update interventions or hold IDT meetings to address the issue. Staff relied mainly on an abdominal binder and signage, with lapses in supervision and communication contributing to the ongoing problem.
A resident with a history of multiple gastrostomy tube (GT) dislodgements did not have an individualized care plan or interventions in place to address and prevent further GT dislodgement, despite repeated incidents and ongoing assessments. The care plan was not updated to reflect the resident's needs, and this was confirmed by the ADON during review.
Surveyors found that both ice machines were not cleaned and sanitized according to the manufacturer's instructions, as the Maintenance Director used a lower concentration and amount of bleach than required and brown residue was observed inside the machines, indicating they were not properly maintained.
Surveyors identified multiple failures in food safety and sanitation, including lack of monitoring for TCS food cooling, improper hand hygiene by kitchen staff, inadequate sanitizing of food contact surfaces, uncleanable kitchen flooring, missing air gap in a food prep sink, unclean and damaged kitchen equipment, improper dry storage practices, and dietary aides wearing large false eyelashes during food preparation. These deficiencies affected a large number of residents receiving meals from the kitchen.
Two residents did not have comprehensive care plans developed to address their individual needs. One resident receiving apixaban for atrial fibrillation did not have a care plan reflecting the use of this anticoagulant, and another resident with cancer, dysphagia, and muscle wasting experienced a 6.5% weight loss in one month without a care plan addressing this significant change. These omissions were confirmed by staff during medical record reviews.
The facility did not follow current professional standards for diabetic diets, continuing to use the outdated 'RCS' (Reduced Concentrated Sweets) terminology across diet orders, care plans, and dietary documentation. The RD acknowledged the inconsistency with current guidelines but had not raised the issue with corporate leadership. Over 50 residents, including a diabetic patient with a recent fracture, were affected by this practice, which persisted due to longstanding facility habits.
A resident who required staff supervision for personal hygiene and grooming did not receive regular nail care, resulting in long, dirty fingernails and self-inflicted skin lesions. Staff confirmed that nail care was their responsibility and that the resident's care plan, which included keeping nails short, was not followed. Documentation showed the last nail care was provided over a month prior, and no further offers were recorded.
A resident admitted with a Stage 3 pressure injury did not receive a low air loss mattress as required, and staff failed to accurately assess new heel blisters and follow a physician's order for a wound consult. The care plan lacked appropriate interventions for bed-bound pressure relief, and staff interviews revealed confusion and lack of follow-up regarding both the mattress and wound consult orders.
A resident with severe cognitive impairment experienced a significant weight loss over one month and was not monitored or assessed as required by facility policy, despite dietary interventions being recommended. Staff and leadership confirmed that the necessary monitoring following the change in condition did not occur.
A resident receiving enteral feeding via GT was not positioned with the head of bed elevated to the required 30-45 degrees during feeding, and the GT feeding bag was not labeled with the date and time it was hung, as required by facility policy. An LVN confirmed both deficiencies during observation and interview.
Multiple residents did not receive safe and appropriate respiratory care due to missing physician orders, lack of care planning, and improper management of respiratory equipment. Staff administered oxygen and performed suctioning without required orders, and respiratory supplies such as oxygen tubing, nebulizer masks, and suction canisters were not dated, labeled, or changed according to policy. Staff interviews confirmed that procedures for labeling, changing, and storing respiratory equipment were not consistently followed.
A resident with a diagnosis of dementia was not properly monitored or had their dementia-related behaviors documented as required by facility policy. Staff observed confusion, agitation, and aggression but did not formally record or assess these behaviors in the medical record, resulting in a lack of documented evidence that appropriate dementia care interventions were being implemented.
The facility did not maintain complete and accurate documentation of controlled medication counts, with missing staff signatures and incomplete records on narcotic count sheets for multiple medication carts. LVNs confirmed that it was their responsibility to perform and document these counts at shift changes, but this was not consistently done, creating the potential for diversion of controlled substances.
Surveyors found that the medication error rate exceeded 5% due to multiple failures by LVNs during medication administration, including cutting unscored tablets, not following physician orders for GT medications, failing to flush between medications, not assessing for loose stools before giving stool softeners, and not providing proper instructions or assessments for residents receiving extended-release or anticoagulant medications.
Surveyors found multiple deficiencies in medication storage and handling, including expired supplies in a treatment cart, staff personal belongings in medication storage rooms, improper segregation of transdermal, topical, oral, and injectable medications, a medication refrigerator outside the required temperature range, and medication carts left unlocked and unattended. Additionally, a resident with severe cognitive impairment had an unlabeled cream at the bedside, and another resident had artificial tears left at the bedside. Staff confirmed these practices did not follow facility policy.
Cooks did not follow established recipes for preparing pureed mandarin chicken and roasted cauliflower, resulting in inconsistent texture and flavor compared to regular menu items. The DTR confirmed the pureed chicken was bland, and the RD verified that recipes should be followed as written. This failure affected 16 residents on pureed diets and risked not meeting their nutritional needs.
A resident admitted under hospice care did not have the required hospice visit calendar or physician certification of terminal illness in their medical record. Multiple LVNs were unable to confirm hospice visit schedules or identify the hospice coordinator, and there was confusion among staff regarding who held this role. The DON later confirmed the social worker as the hospice coordinator and acknowledged the missing documentation.
Two residents were found self-administering medications at their bedside without proper assessment, physician orders, or care plans in place. One resident with decision-making capacity was using multiple eye drop medications without education on correct administration, while another resident with moderately impaired cognition had an antifungal powder at her bedside and no documentation supporting self-administration. Staff were unaware of the presence of these medications, and facility policy requiring IDT assessment and documentation for self-administration was not followed.
Two residents' advance healthcare directives were not properly honored or maintained. One resident's directive, which designated a specific healthcare agent and a choice not to prolong life, was not reflected in the POLST form, which instead authorized CPR and was signed by a different family member. For another resident, the advance directive provided by family was not uploaded or made accessible in the medical record, despite documentation indicating it was received. These failures resulted in the potential for residents' healthcare decisions not being followed.
Several residents with cognitive impairments were found to have personal belongings and other items placed on top of their overbed light fixtures, including picture frames, toys, flower cards, and a piece of wood. Staff confirmed the presence of these items but had not reported or removed them, and maintenance checks or requests were not documented. The deficiency was identified through direct observation and staff interviews.
A CNA did not receive a required annual performance evaluation, as confirmed by facility policy and interviews with the DSD and DON. The last evaluation for the CNA was conducted more than a year prior, and the facility's process for regular review of employee files was not followed.
The facility failed to maintain complete and accurate medical records by not uploading the most current POLST form for a resident, leaving a previous form unvoided, and having multiple missing or incomplete entries for CNA documentation of turning, repositioning, and personal hygiene for several residents, including those with severe cognitive impairment and total dependence on staff. Facility leadership confirmed that documentation was not completed as required by policy.
The facility failed to enforce infection control policies by allowing symptomatic staff to work while awaiting COVID-19 test results, did not maintain clean laundry equipment, and did not consistently implement Enhanced Barrier Precautions for residents with medical devices. Additionally, a resident's meal tray was placed next to a used urinal without proper care plan documentation, and staff confirmed these practices did not follow infection control protocols.
A resident with severe cognitive impairment and significant assistance needs was found without access to a functioning call light, as the cord was cut off from the wall panel. Staff interviews confirmed the issue had not been previously reported, and the maintenance department was unaware of the problem until it was brought to their attention.
Staff assisted two residents with severe cognitive impairment and high dependence for eating while standing over them, rather than sitting at eye level as required by facility policy. Both staff members acknowledged the policy but cited a lack of available chairs as the reason for not following it, and the DSD confirmed the expectation to sit beside residents during meal assistance to promote dignity.
A laptop displaying a resident's personal health information, including name and scheduled medications, was left open and unattended on a medication cart in a hallway. Staff and another resident passed by the exposed screen, and an LVN confirmed she had left the laptop unattended without logging out or closing it.
Two residents were found to have rooms with damaged walls, including scratches, chipped paint, and non-penetrating holes, which were not reported for repair in the maintenance logbook as required by facility policy. The Maintenance Director confirmed the lack of repair requests and the presence of the deficiencies during observations.
During an inspection, black residue suggestive of mold was found along the walls in two shower rooms, with staff unable to provide cleaning documentation. In another shower room, an overloaded soiled linen barrel, an unlabeled portable toilet basin on the floor, and a diaper on a commode chair were observed. Additionally, a shower chair with a brownish stain, appearing to be fecal matter, was found, with staff confirming that cleaning protocols were not followed.
The facility failed to maintain infection control practices for residents on contact isolation. Staff entered rooms without donning required PPE or performing hand hygiene, despite precautionary signage. Interviews revealed a lack of awareness among staff about isolation status, indicating ineffective communication of infection control measures.
The facility failed to provide timely ADL assistance, with residents experiencing significant delays in call light responses, particularly during night shifts. Two residents reported waiting over two hours for help, leading to self-assistance in one case. CNAs confirmed that residents were often found in soiled briefs in the morning, and the buddy system was not effectively utilized. The ADON acknowledged a performance issue among staff, rather than a staffing shortage.
A facility failed to prevent the development or worsening of pressure ulcers for a resident who was unable to make medical decisions. The facility did not notify the resident's RP about changes in skin condition and failed to develop care plans for new skin issues. The care plan intervention to float the resident's heels was not followed, as confirmed by an LVN and the ADON.
The facility failed to prevent and manage pressure injuries for two residents. One resident's discharge skin assessment was incomplete for a Stage 2 pressure injury, while another resident's low air loss mattress was found unplugged, compromising care for an unstageable pressure injury.
A facility failed to maintain complete and accurate medical records for a resident, leading to potential inadequate care. The resident's care plan for pressure ulcers and incontinence was not fully documented, with missing entries for bladder and bowel incontinence and turning and repositioning. Additionally, there were discrepancies in Foley catheter care documentation, as the catheter was noted as removed, yet records indicated care was still being documented. These issues were confirmed by facility staff.
A resident's call light was not within reach, potentially delaying assistance. The facility's policy required call lights to be accessible from various locations, including the bed and bathroom. During an observation, a CNA confirmed the call light was on the pillow, out of reach, while the resident called for help. The Administrator and ADON acknowledged the issue.
A deficiency was identified in a facility's process for protecting a resident's personal property during discharge. The facility failed to ensure that the personal effects inventory was reviewed and signed off by the resident or responsible party and the discharging nurse. This oversight was confirmed through interviews with RN 1 and the DON, highlighting a lapse in following the facility's policy and procedure, which could lead to the loss or theft of the resident's belongings.
The facility failed to provide TV remote controls for a resident and two other residents, impacting their ability to watch TV. The Maintenance Director confirmed that each bed should have a remote control, but the residents reported the absence of remotes and lack of action after informing staff.
A resident with multiple skin issues, including diabetic ulcers and skin discoloration, did not receive the required weekly and discharge skin assessments as per the facility's policy. Interviews with an LVN and the DON confirmed the assessments were missed, and there was no documentation or photographs of the wounds, indicating a lapse in procedure adherence.
A facility failed to inform a resident of dosage changes in their psychotropic medications, amitriptyline and sertraline, and did not obtain informed consent prior to administering increased dosages. The resident, capable of understanding and making decisions, was not informed of these changes, as confirmed by the QA Nurse and DON. This oversight was identified through interviews and medical record reviews.
Two residents were not invited to participate in their interdisciplinary team (IDT) behavior management conferences, despite having the capacity to understand and make decisions. The facility's policy encourages resident participation in care planning, but documentation showed no evidence of such encouragement. The ADON and DON acknowledged the oversight, confirming the residents' non-participation in the meetings.
The facility failed to maintain infection control standards when a nurse placed personal belongings on a treatment cart and a resident's nasal cannula was found on the floor. The DON acknowledged the issue, and an LVN confirmed the nasal cannula should have been stored properly.
The facility failed to provide quality care for three residents, leading to several deficiencies. A resident was not assessed or documented after an unwitnessed fall, and neurological monitoring was incomplete for two residents after falls. Another resident had low oxygen saturation levels without physician notification, underwent a manual fecal disimpaction without a physician's order, and did not receive PRN bowel movement medications as ordered.
The facility failed to implement floor mats for a resident as per the physician's order and care plan, despite the resident's documented risk for falls. Observations and interviews confirmed the absence of floor mats, placing the resident at risk for serious injury.
A resident was administered midodrine outside of the physician's ordered parameters, with the medication given when the resident's systolic blood pressure was greater than 130 mmHg. This occurred on two occasions, contrary to the facility's policy and procedure for administering medications.
The facility failed to develop and implement a care plan for a resident's CPAP use, despite physician's orders and the resident's diagnosis of obstructive sleep apnea. An LVN confirmed the oversight, and the DON acknowledged the deficiency.
The facility failed to administer sevelamer carbonate as ordered for a resident on hemodialysis days. The medication was not given at the prescribed time due to the resident being out of the facility, and there was no documentation of re-offering the medication upon the resident's return.
Verbal Abuse of a Cognitively Intact Resident by Dietary Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. The facility’s Abuse Prevention Program policy stated that residents have the right to be free from abuse. The involved resident had diagnoses including anxiety disorder and depression, was cognitively intact, and had expressed increased anxiety about having another heart attack. On the date of the incident, the resident returned to the kitchen because the meal tray provided was not to her liking, and kitchen staff prepared a new tray. A dietary aide carried the new tray and walked back to the resident’s room with the resident, during which staff overheard them talking loudly and heard the resident call the aide names. When the dietary aide later returned to the resident’s room to bring yogurt, the resident yelled at the aide, and the aide responded by yelling, cursing, and making derogatory comments toward the resident, including calling her “crazy.” CNA witnesses reported hearing the aide curse at the resident, and one CNA observed the resident crying and not understanding why the aide acted that way. A Change in Condition Evaluation documented that the resident experienced increased anxiety and brief situational emotional distress related to the altercation with the dietary aide, though she returned to baseline with reassurance. The facility’s internal conclusion acknowledged that staff should not respond with profanity toward a resident regardless of the resident’s behavior, and the DON verified the findings.
Failure to Perform Required Post–Change in Condition Monitoring After Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to provide required nursing assessments and monitoring following a resident’s change in condition related to an incident of verbal abuse. The facility’s Abuse and Neglect – Clinical Protocol policy stated that staff and the physician would monitor individuals who have been abused to address issues regarding their medical condition, mood, and function. The resident involved had diagnoses including anxiety disorder and depression, was documented as cognitively intact, and had previously expressed increased anxiety about having another heart attack. After a dietary aide was observed yelling at the resident, a Change in Condition Evaluation documented that the resident experienced increased anxiety and brief situational emotional distress related to the altercation, and then returned to baseline with reassurance. The resident’s care plan was updated with a problem addressing the verbal abuse incident, including an intervention to monitor the resident for 72 hours for changes in routine and symptoms of distress. Facility staff, including an LVN and the ADON, stated that following a change in condition, nursing staff were supposed to assess and monitor the resident every shift for 72 hours, focusing on the change in condition to ensure proper interventions and to notify the physician if needed. The ADON stated that the purpose of the follow-up assessments for this resident was to ensure the resident felt safe and comfortable and to assess for any pain. The ADON verified that the resident was not monitored following the verbal abuse allegation on the morning of 2/10/26 and that all assessments were missed on 2/11/26, and the DON confirmed these findings.
Failure to Prevent and Investigate Repeated Gastrostomy Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received appropriate care and services to prevent complications related to repeated dislodgement of the GT. The resident experienced multiple incidents of GT dislodgement on at least seven separate occasions, each requiring medical intervention and replacement of the tube. Despite these repeated events, the facility did not conduct assessments or document investigations into the possible causes of the dislodgements, except for one incident. There was also no evidence of updated or modified interventions to prevent further occurrences, and no interdisciplinary team (IDT) meetings were held to address the frequent GT dislodgement. Staff interviews revealed that the primary intervention implemented was the use of an abdominal binder to prevent the resident from pulling at the GT, along with a sign instructing staff to keep the resident's right arm outside the sheets. However, staff also reported that the GT had been pulled out by staff during repositioning and that there were lapses in supervision, such as leaving the resident alone without the abdominal binder during shower preparation. Additionally, the shower team was not consistently informed about high-risk residents prior to showers. The facility's lack of investigation, documentation, and updated interventions contributed to the ongoing issue of GT dislodgement for this resident.
Failure to Develop and Implement Individualized Care Plan for GT Dislodgement
Penalty
Summary
The facility failed to develop and implement an individualized care plan to address and prevent the repeated dislodgement of a resident's gastrostomy tube (GT). Despite multiple documented incidents where the resident's GT became dislodged, the care plan did not include a specific problem statement or interventions aimed at minimizing the risk of further dislodgement. The facility's policy requires that care plans reflect current standards of practice, be person-centered, and be updated as residents' conditions change, but this was not followed in the case of this resident. Medical record review showed several change of condition assessments related to the dislodged GT over a period of time, yet the care plan was not revised to address this recurring issue. During an interview and concurrent record review, the Assistant Director of Nursing (ADON) confirmed that a care plan to prevent GT dislodgement should have been developed for the resident, but was not present. This resulted in the resident not receiving appropriate, consistent, and individualized care to address the risk of GT dislodgement.
Ice Machines Not Cleaned per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that both of its ice machines were cleaned and maintained according to the manufacturer's guidelines. The manufacturer's instructions, posted inside the machines, specified the use of 1.7 fluid ounces of 8.25% sodium hypochlorite (chlorine bleach) for sanitizing. However, the Maintenance Director reported using only 1.5 fluid ounces of 7.5% Clorox bleach for all ice machines, which did not meet the specified concentration or amount required by the manufacturer. Additionally, the facility's own policy and procedure, revised in November 2022, required adherence to the manufacturer's instructions for cleaning and disinfecting ice machines and storage chests. During observations of both ice machines, brown residue was found inside the ice chutes, which was removed with a paper towel, confirming that the machines were not clean. The Maintenance Director acknowledged that the cleaning and sanitizing process did not follow the manufacturer's guidelines and verified the presence of residue. No information about residents or their medical conditions was provided in relation to this deficiency.
Multiple Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines in several critical areas, as observed and documented by surveyors. The cool down process for time/temperature control for safety (TCS) foods was not monitored or documented, and previously cooked foods were kept beyond recommended time limits. Staff interviews confirmed that cooling logs did not include required entries for both cooked and ambient temperature TCS foods, such as tuna and egg salad, and that staff were unaware of proper monitoring procedures. Additionally, food items in the refrigerator were found with missing or outdated labels, and some foods were stored longer than recommended by USDA guidelines. Hand hygiene practices among kitchen staff were inadequate. Two of three cooks failed to wash their hands after activities that could cause contamination, such as retrieving items from storage, touching their clothing, or picking up utensils from the floor. These lapses were observed during food preparation and confirmed in interviews with the Registered Dietitian (RD), who acknowledged that staff must wash hands when changing tasks or after contamination. Furthermore, food preparation surfaces were not properly sanitized, as the concentration of sanitizing solution in use was below the effective level required for food contact surfaces. Staff and management confirmed that the sanitizer was not at the correct concentration and that this issue was not being consistently addressed. The physical environment and equipment in the kitchen also failed to meet sanitation standards. The kitchen floor in front of a freezer was unfinished concrete, making it uncleanable, and a food preparation sink lacked an air gap, creating a risk of backflow contamination. Equipment such as drying racks and meal trays were found to be rusted, chipped, and cracked, and a container in dry storage had a cracked lid. Goods in dry storage were not protected from possible pest contamination. Additionally, two dietary aides were observed wearing large false eyelashes during food preparation, which is not recommended due to the risk of physical contamination. These deficiencies affected a highly susceptible population of 156 residents who consumed food prepared in the facility's kitchen.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use and Significant Weight Loss
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of two residents. For one resident with a diagnosis of paroxysmal atrial fibrillation, a physician ordered apixaban, an anticoagulant medication, but the resident's care plan did not include any interventions or monitoring related to the use of this medication. This omission was confirmed during a medical record review and interview with a licensed nurse, who acknowledged that the care plan should have been updated when the medication was ordered. Another resident, admitted with diagnoses including malignant neoplasm of the esophagus, dysphagia, and muscle wasting, experienced a significant weight loss of 6.5% in one month, as documented in weekly weight records. Despite this notable change, there was no evidence in the resident's care plan that addressed the weight loss. This finding was verified during a review of the medical record with the assistant director of nursing.
Failure to Update Diabetic Diet Terminology to Meet Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following the current diet manual recommendations for diabetic diets. Specifically, the facility continued to use the term "RCS" (Reduced Concentrated Sweets) for diabetic diets, despite guidance from the Academy of Nutrition and Dietetics and the American Diabetes Association indicating that such terminology is outdated and not reflective of current nutrition recommendations. The facility's diet manual, menus, tray cards, and dietary documentation all used the RCS nomenclature, and the Registered Dietitian (RD) confirmed that this terminology was used interchangeably with the Consistent Carbohydrate (CC) diet, even though RCS is not a recognized diet by professional organizations. Interviews with the RD revealed that she was aware of the discrepancy between the terminology used at the facility and current professional standards but had not communicated her concerns to the Corporate RD. The RD stated that the facility had always used the RCS terminology for diabetic diets and continued to do so after the implementation of their electronic health record system. The RD also confirmed that she was responsible for the nutrition care plans of all residents on these diets and that the care plans reflected the diet as ordered, using the RCS terminology. A review of facility records showed that 51 residents were receiving an RCS diet, with various modifications such as fortified, high protein, or renal adjustments. One resident with diabetes and a recent fracture was specifically noted to have an RCS NAS regular consistency diet ordered by the physician, and the RD confirmed that this was documented in the care plan and dietary records. The Director of Nursing (DON) also verified that the RCS nomenclature was used because it had been the facility's longstanding practice.
Failure to Provide Adequate Nail Care Resulting in Self-Inflicted Skin Lesions
Penalty
Summary
A deficiency was identified when a resident who required staff supervision for personal hygiene and grooming did not receive adequate nail care. During observations, the resident was seen scratching her face, neck, and arms, resulting in multiple small red lesions. The resident's fingernails were noted to be long, with black stains and food residue underneath. The care plan for this resident specifically included an intervention to keep fingernails short due to a history of self-inflicted excoriations. However, documentation showed that the last time the resident's fingernails were clipped was over a month prior, and there was no record of nail care being offered since then. Interviews with staff confirmed that providing nail care was a CNA responsibility and that the resident's care plan should have been followed. Both the CNA and LVN verified the resident's nails were long and dirty, which contributed to skin impairment. The ADON acknowledged that failure to provide personal hygiene and grooming, including nail care, could affect the resident's dignity and potentially lead to bacterial growth. The facility's policy required assistance with activities of daily living, including grooming and hygiene, for residents unable to perform these tasks independently.
Failure to Provide Pressure Ulcer Prevention and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for a resident admitted with a Stage 3 pressure injury on the sacrum. Despite being identified as high risk for pressure injury on Braden Scale assessments, the resident was not provided with a low air loss mattress as required by facility policy and physician order. Multiple observations confirmed the resident was resting and sleeping in bed without the appropriate pressure-relieving mattress, and staff interviews revealed confusion and lack of follow-up regarding the mattress order, with insurance issues cited as a reason for the delay. The case manager was unaware of the need for the mattress, and the ADON acknowledged the resident should have received one within a month of admission. Additionally, the facility failed to ensure accurate skin assessment for the resident, who developed blisters on both heels. Staff interviews revealed inconsistent understanding of pressure injury staging, with one LVN incorrectly stating that an intact blister on the heel was not a Stage 2 pressure injury, while the ADON confirmed it should be considered as such. The care plan addressed the need for a pressure-relieving device for the wheelchair but did not include an intervention for the bed, despite the resident's decreased mobility and incontinence, which were identified as contributing factors for further skin breakdown. Furthermore, the facility did not follow the physician's order for a wound consult. Although a wound consult was ordered due to the Stage 3 pressure injury, staff interviews and record reviews confirmed that the order was not followed up or completed. The LVN responsible was unaware of the order, and the wound physician had not been consulted for the resident. These failures had the potential to contribute to the deterioration of the resident's existing pressure injuries and the development of new ones.
Failure to Monitor Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to monitor a resident who experienced a significant weight loss of 6.71% in one month. According to the facility's policies and procedures, a weight loss of 5% or more in one month is considered a significant change of condition, requiring assessment and monitoring. The resident, who had severe cognitive impairment, was noted by the registered dietitian to have lost weight likely due to a recent acute care hospitalization, and dietary interventions were recommended, including increased milk intake and weekly monitoring of weights, oral intake, laboratory tests, and skin condition. Despite these recommendations and the facility's own protocols, there was no documented evidence that the resident was assessed or monitored for the significant weight loss. Observations showed the resident consumed only 20% of a lunch meal on one occasion, though intake was higher at breakfast on another day. Interviews with staff confirmed that the required monitoring and assessment following the change in condition did not occur. Facility leadership acknowledged that the resident was not monitored as required after the significant weight loss.
Failure to Ensure Proper Positioning and Labeling During Enteral Feeding
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident receiving enteral feeding. Specifically, the resident was observed in bed with the head of the bed only slightly elevated, not meeting the required 30 to 45 degrees elevation during GT feeding as ordered by the physician and outlined in the facility's policy and procedure. This was confirmed during an observation and interview with an LVN, who verified that the resident's head of bed was not properly elevated while the GT feeding was in progress. Additionally, the GT feeding bag containing Fibersource 1.2 was not labeled with the date and time it was hung, contrary to the facility's policy which requires such labeling to ensure safe administration and monitoring of enteral nutrition. The LVN also confirmed that the feeding bag was missing the required label. These failures were identified through observation, interview, and review of the resident's medical record and facility policies.
Failure to Provide Safe and Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care for multiple residents, as evidenced by a lack of physician orders, incomplete care planning, and improper management of respiratory equipment. For example, one resident was administered oxygen without a physician's order or a corresponding care plan, and suctioning was performed without an order. Observations revealed that respiratory equipment such as suction canisters and catheters were undated, unlabeled, and not stored in set-up bags as required by facility policy. Another resident was found to be receiving oxygen at a rate higher than prescribed by the physician, with undated nasal cannula tubing and a set-up bag that was not changed weekly. Additional residents had respiratory therapy equipment, such as nebulizer masks and oxygen tubing, that were not dated or changed according to the facility's infection control policies. In several cases, the required set-up bags for storing respiratory equipment when not in use were missing, and equipment was not labeled with the resident's name or date as required. Interviews with staff, including LVNs, the Central Supply Manager, and the DON, confirmed that respiratory supplies were not consistently labeled, changed, or stored according to policy. The facility's own policies required weekly changes and proper labeling of respiratory equipment, but these procedures were not followed for several residents. These failures were observed across multiple residents and confirmed through staff interviews and medical record reviews.
Failure to Document and Monitor Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for a resident diagnosed with dementia, as required by its own policies and procedures. The resident, who had a history of dementia and was noted to lack capacity for medical decision-making, was observed to be confused, sometimes agitated, and in need of reminders to eat. Staff interviews revealed that while changes in the resident's behavior, such as agitation and aggression, were verbally reported to the charge nurse, there was no documentation or formal monitoring of these behaviors in the medical record as outlined in the resident's care plan. Review of the resident's care plan indicated that staff were to monitor for changes in condition and behaviors related to dementia and report these findings to the physician. However, both CNA and LVN staff confirmed that they did not document altered behaviors or assess for changes in the resident's thought process, despite observing such behaviors. The lack of documentation and monitoring meant that the resident's dementia-related symptoms and potential changes in condition were not being formally tracked or communicated as required.
Failure to Document and Safeguard Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not maintaining complete and accurate documentation on the Narcotic Card/Bottle Count Sheets for multiple medication carts over several months. Specifically, for Medication Cart C in February and March, and Medication Cart D in February and April, there were numerous instances where required staff signatures were missing for both incoming and outgoing shifts across all three daily shifts. Additionally, there were several occasions where the total number of narcotic cards and bottles was not documented by either on-duty or off-duty staff as required. These deficiencies were confirmed during interviews and concurrent document reviews with licensed vocational nurses, who acknowledged that it was the responsibility of licensed nurses to count and sign for the narcotic cards and bottles at the start of their shifts. The lack of proper documentation and signatures on the count sheets had the potential for controlled substance diversion, as the facility did not ensure that the required procedures for tracking and safeguarding controlled medications were consistently followed.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 23.07%. During medication administration observations, three LVNs were found to have made multiple errors. One LVN cut an unscored vitamin C tablet in half for a resident, contrary to best practices and without a physician's order, resulting in the administration of an inaccurate dose. The same LVN also failed to administer the correct dosages and types of medications to another resident via gastrostomy tube (GT), did not flush the GT between medications, mixed multiple medications together, and did not check for loose stools before administering a stool softener, as required by the physician's order. Another LVN did not follow physician's orders when administering a calcium with vitamin D supplement to a resident, failed to instruct the resident not to chew an extended-release medication, and did not assess for signs of bleeding or bruising prior to administering an anticoagulant. The medication administration record and medication packaging indicated that the extended-release medication should not be chewed or crushed, but the resident was observed breaking the tablet to swallow it more easily, without being advised otherwise by the nurse. A third LVN administered a stool softener to a resident without assessing for loose bowel movements, despite a clear physician's order to hold the medication if the resident had loose stools. In interviews, the LVNs acknowledged the errors and confirmed that they did not follow the required procedures or physician's orders during medication administration. The DON confirmed that nurses are expected to be competent in medication administration and to follow all orders and protocols.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Multiple deficiencies were identified regarding the storage, labeling, and disposal of medications and supplies. Expired treatment supplies, such as culture swabs, were found in a treatment cart, and staff confirmed these items should not have been present. Medication storage rooms contained staff personal belongings, and medications were not properly segregated by type, with transdermal patches stored alongside oral medications and artificial tears stored with oral medications. The medication refrigerator was found to be outside the acceptable temperature range, and staff acknowledged this deviation from policy. Further observations revealed that topical and oral medications were stored together in medication carts, such as antifungal cream with oral tablets and suspensions, and injectable medications were stored with inhalant medications. Discontinued medications were not removed from medication carts, and medication carts were left unlocked and unattended. A white capsule was found on a resident's bed, despite the resident not being authorized for self-administration, and the nurse confirmed the medication should have been administered and not left with the resident. Additional deficiencies included unlabeled and resident-specific creams left at the bedside of a resident with severe cognitive impairment, and artificial tears eye drops were found at another resident's bedside. Staff verified that these items should not have been accessible to residents in this manner. The facility's policies and procedures required medications and biologicals to be stored in locked compartments and maintained under proper conditions, but these were not consistently followed, as evidenced by the findings.
Failure to Follow Pureed Food Preparation Procedures
Penalty
Summary
The facility failed to ensure that cooks followed proper procedures for preparing pureed food, specifically for mandarin chicken and roasted cauliflower. During observation, it was noted that the cook preparing the pureed mandarin chicken did not follow the facility's recipe, which required the addition of mandarin sauce to the chicken before pureeing. Instead, only plain boiled chicken, water, and thickener were used, resulting in a pureed product that was bland and did not match the flavor of the regular texture dish. The dietetic technician registered (DTR) confirmed that the pureed mandarin chicken lacked the same flavor as the regular version. For the pureed roasted cauliflower, the cook did not initially follow the recipe instructions, which required blending the roasted cauliflower before determining if additional liquid or thickener was needed. Instead, the cook added water and thickener before blending, and repeatedly added more water to achieve the correct consistency. The cook acknowledged not following the recipe after being prompted to read the instructions and had to restart the process to comply with the proper method. Interviews with the registered dietitian (RD) confirmed that all recipes should be followed as written. The failure to adhere to established recipes and procedures for pureed foods created a risk for inconsistent products and the potential for not meeting the nutritional needs of the 16 residents who required a pureed diet.
Failure to Maintain Hospice Documentation and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had all necessary documentation and coordination in place. Specifically, the hospice visit calendar and the physician certification of terminal illness were not available in the resident's medical record. Multiple staff members, including LVNs, were unable to confirm the schedule of hospice visits or the identity of the hospice coordinator. The hospice binder did not contain the required calendar for scheduled visits, and staff were unsure about the frequency of hospice visits for the resident. Additionally, there was confusion among staff regarding who was designated as the hospice coordinator, with different staff members identifying either the QA Nurse or the social service department. Interviews with staff revealed a lack of awareness about hospice visit documentation and the process for communicating with the hospice provider. One LVN was unaware of whether hospice had visited regarding a specific equipment request and had to rely on a sign-in sheet for confirmation. Another LVN was unable to provide the physician's certification for hospice benefits when asked. The Director of Nursing later confirmed that the social worker was the hospice coordinator and acknowledged the findings related to missing documentation and unclear staff roles.
Failure to Assess and Care Plan for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly assessed and care planned for self-administration of medications, as required by facility policy. One resident was found with three bottles of eye drops at her bedside, which she self-administered without a physician's order or a documented assessment by the interdisciplinary team (IDT) to determine her ability to safely self-administer these medications. The resident was not provided with education on the correct technique for administering the eye drops, as she reported not knowing how long to keep her eyes closed after application and often opened them immediately after use. Review of her medical record confirmed the absence of a physician's order and a care plan addressing self-administration of these medications, despite her having the capacity to make medical decisions. Another resident was observed with an antifungal powder at her bedside, which she reported possibly using once but could not recall who provided it. This resident's medical record indicated moderately impaired cognition, and there was no physician's order, assessment for self-administration, or care plan for the use of this medication. Staff interviews confirmed that the medication was not authorized to be kept at the bedside and that the resident and her family had not been educated on the facility's protocol regarding self-administration and storage of medications. Facility policy requires that residents may only self-administer medications if the IDT determines it is clinically appropriate and safe, with documentation in the medical record and care plan, and with periodic reassessment. Any medications found at the bedside without authorization are to be removed. In both cases, these procedures were not followed, resulting in unauthorized self-administration of medications without proper assessment, documentation, or education.
Failure to Honor and Maintain Advance Healthcare Directives
Penalty
Summary
The facility failed to honor the advance healthcare directives for two residents, resulting in deficiencies related to the residents' rights to have their healthcare decisions respected. For one resident with severe cognitive impairment, the advance healthcare directive designated a specific family member as the healthcare agent and indicated a preference not to prolong life. However, the resident's medical record contained a POLST form that authorized CPR and artificial nutrition, was signed by a different family member, and incorrectly stated that no advance directive was available. Both the registered nurse and the social services director confirmed that the POLST form did not match the resident's documented wishes or the designated healthcare agent. For another resident who was cognitively intact, the facility failed to maintain a copy of the advance healthcare directive in the medical record. Although the resident's family provided the directive and documentation indicated it was received by the medical records department, the document was not uploaded or made readily retrievable in the electronic health record. Multiple staff interviews confirmed that the advance directive was not available in the resident's record, despite the POLST form indicating it had been reviewed. The facility's policy required that advance directives be obtained, maintained in a consistent and accessible section of the medical record, and that the resident's wishes be communicated to care staff and reflected in the plan of care. These requirements were not met for the two residents, resulting in the potential for their healthcare decisions and treatment preferences not being honored.
Failure to Prevent Accident Hazards Due to Items Placed on Overbed Light Fixtures
Penalty
Summary
The facility failed to ensure that certain resident areas were free from accident hazards, specifically by allowing personal belongings and other items to be placed on top of overbed light fixtures in the rooms of three residents. For one resident, two picture frames, a hat, and two stuffed toys were observed on top of the overhead light fixture. Staff, including an LVN and the Maintenance Director, confirmed these items were present and acknowledged that such placement could weaken the fixture and potentially result in items falling. The Maintenance Director noted that the resident had recently been transferred to the room and that monthly checks were conducted, but no maintenance request had been logged to address the issue. The DON stated that all staff were responsible for checking resident rooms and ensuring safety, but no action had been taken to remove the items or report the hazard. In two other cases, two pop-up flower cards and a piece of wood were found on top of overbed light fixtures in the rooms of residents with severe cognitive impairment. Staff interviews revealed that CNAs had not noticed or addressed the items, and the Maintenance Director confirmed the presence of these hazards during observations. The Maintenance Director also removed a metal drawer slide bracket from one of the fixtures, stating that no items should be placed on top of overbed light fixtures. Medical record reviews indicated that the affected residents had moderate to severe cognitive impairments, which may have limited their ability to recognize or report such hazards.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete annual performance evaluations for one of two reviewed certified nurse aides (CNA 1), as required by its policy. The facility's policy, revised in September 2020, mandates that each employee's job performance be reviewed and evaluated at least annually by department directors and supervisors, with further review by the director of human resources. During an interview and document review, the Director of Staff Development (DSD) confirmed that CNA 1's last performance evaluation was conducted on 11/16/22, and acknowledged that employee files should be reviewed regularly based on the date of hire. The Director of Nursing (DON) also acknowledged that the policy on performance evaluations was not followed.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and professional standards. For one resident, the most current POLST (Physician Orders for Life-Sustaining Treatment) form was not uploaded into the electronic health record, and a previous POLST form indicating a different code status was not voided. This resulted in conflicting information regarding the resident's code status, as the electronic record showed a full code while a physician's order indicated DNR (Do Not Resuscitate). The Medical Records Director confirmed that the current POLST form was not uploaded because she had not yet accessed the binder, and the previous form remained in the record unvoided. Additionally, documentation for turning and repositioning, personal hygiene, oral hygiene, toileting hygiene, and pressure reduction was incomplete or missing for multiple residents, including those with severe cognitive impairment and total dependence on staff for ADL (Activities of Daily Living) care. Reviews of documentation survey reports revealed numerous missing entries across various shifts, with some tasks incorrectly coded as 'not applicable' or left blank. Interviews with the DON and ADON confirmed that CNAs were expected to document care at the end of their shifts and that missing or incorrect documentation could indicate that care was not provided or not properly recorded. The facility's policies required that all procedures and treatments be documented with specific details, including the date, time, care provided, and the staff member responsible. However, for several residents, these requirements were not met, as evidenced by the missing or incomplete documentation in their records. The DON and ADON verified these findings during interviews and acknowledged that the documentation did not meet facility standards.
Infection Control Program Failures and Lapses in Staff Work Restrictions
Penalty
Summary
The facility failed to maintain its infection prevention and control program, resulting in several deficiencies related to the prevention and transmission of communicable diseases. Staff members with symptoms of COVID-19 were not restricted from working while awaiting test results, contrary to facility policy and CDC guidelines. Specifically, a CNA reported symptoms such as sneezing, headache, watery eyes, and back pain, which were communicated to the Director of Staff Development (DSD), but the CNA was allowed to continue working until the end of her shift and returned to work the following day. The CNA later tested positive for COVID-19. Similarly, an LVN who tested positive for COVID-19 continued to work until notified of her result, and there was a lack of immediate communication and follow-up regarding her work restriction. The Infection Preventionist (IP) and DSD did not ensure that symptomatic staff were promptly removed from the schedule, and the Director of Nursing (DON) and Administrator were not made aware of these lapses at the time they occurred. The facility also failed to maintain clean laundry equipment, as observed during an inspection of the laundry room. One washing machine was found with heavy buildup of black, yellow, and white sediments on various parts, despite claims of daily cleaning by the Housekeeping Supervisor. The IP confirmed that such buildup could serve as a breeding ground for bacteria and that equipment should be kept clean to prevent infection. This lack of proper maintenance of laundry equipment posed a risk of contamination for residents' laundry. Additional deficiencies were identified in the implementation of Enhanced Barrier Precautions (EBP) for residents with medical devices such as gastrostomy tubes (GT). During wound care for a resident with a GT, an LVN failed to don a gown before performing care, only putting it on after beginning the procedure. Another resident with a GT did not have EBP signage or precautions in place, despite care plan orders and policy requirements. Furthermore, a resident's meal tray was placed on a bedside table next to a used urinal containing urine, and there was no care plan documentation addressing the resident's preference to keep the urinal at the bedside. Staff interviews confirmed that this practice was not in line with infection control policies.
Failure to Provide Functioning Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident was found without access to a functioning call light in their room. During an initial facility tour, the resident was observed awake and lying in bed, with the call light not within reach. Further inspection revealed that the call light cord had been cut off from the wall panel, leaving the resident without a means to summon staff for assistance. The facility's policy requires that call lights be plugged in and functioning at all times to ensure timely responses to residents' needs. Medical record review showed the resident had severe cognitive impairment but retained upper extremity function and required substantial to maximal assistance for bed mobility, transfers, dressing, and toileting. Interviews with staff confirmed that the resident's call light was not operational and that staff had not noticed or reported the issue prior to its discovery. The maintenance director stated that the maintenance department checks the call light system weekly but had not received any report about this specific call light until the day before the interview.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide meal assistance in a manner that promoted dignity and respect for two residents with severe cognitive impairment and high dependence on staff for eating. In both cases, staff members were observed standing over the residents, who were seated in bed, while assisting them with meals. The staff acknowledged during interviews that facility policy required them to sit beside or at eye level with residents during meal assistance to ensure dignity, but they did not do so because no chairs were available at the time. Medical record reviews confirmed that both residents required substantial or maximal assistance with eating due to severe cognitive impairment. The Director of Staff Development also confirmed the facility's policy of sitting beside or at eye level with residents during meal assistance. The failure to follow this policy was directly observed and acknowledged by the staff involved.
Unattended Laptop Exposes Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information when a laptop displaying the resident's name and scheduled medications was left open and unattended on top of a medication cart in the hallway near the nurses' station. During the observation, staff and another resident were seen passing by the area where the laptop was left exposed. An LVN confirmed that she had left the laptop open and unattended, acknowledging that she should have logged out or closed the device to protect the resident's information.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents, as evidenced by the condition of their rooms. In one instance, a resident's room had multiple vertical scratches, chipped paint, and non-penetrating holes along the wall at the head of the bed, extending down to the baseboard. In another room, the wall near the headboard and bedside table was observed with chipped wood, chipped paint, multiple scratches, and non-penetrating holes. Both residents were present in their rooms at the time of observation and confirmed awareness of the wall conditions. Review of facility policies indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards, with a process in place for staff to report needed repairs through a maintenance logbook. However, there was no documentation in the maintenance logbook for either room, and the Maintenance Director confirmed that no repair requests had been submitted for these deficiencies.
Failure to Maintain Sanitary and Safe Conditions in Multiple Shower Rooms
Penalty
Summary
Multiple deficiencies were identified during an environmental inspection of the facility, specifically related to the maintenance of a safe, functional, and sanitary environment in several shower rooms. In Shower Rooms B and D, black residue was observed along the perimeter of the walls, with the Maintenance Supervisor and an LVN both acknowledging that the residue could indicate mold growth. The Maintenance Supervisor stated that the housekeeping staff were responsible for cleaning the tiles, but was unable to provide documentation confirming that the showers had been cleaned. Additionally, Shower Room B was designated for residents with COVID-19, and the Maintenance Supervisor confirmed that reports of this issue had been received previously. Further observations in Shower Room D revealed an open and overloaded linen barrel containing soiled linen, an unlabeled portable toilet basin on the floor, and a diaper placed on top of a wheeled commode chair. In Shower Room C, one of five shower chairs was found with a brownish stain on the foam seat, appearing to be fecal matter. The Maintenance Director confirmed that CNAs were supposed to clean the shower chairs after each use. These findings were verified by facility staff during the inspection and interviews.
Failure to Adhere to Infection Control Practices
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) for residents on contact isolation. Observations revealed that staff members entered rooms marked with contact precautions without donning the required PPE, such as gloves and gowns, and without performing hand hygiene. For instance, a Certified Nursing Assistant (CNA) entered a resident's room without gloves or a gown and handled linens with bare hands. Another CNA entered the same room with gloves and a mask but failed to perform hand hygiene before and after the visit. Additionally, a Licensed Vocational Nurse (LVN) entered a different room on contact precautions without wearing an isolation gown and was unaware of the isolation status. Interviews with the staff indicated a lack of awareness regarding the isolation status of the rooms, despite the presence of precautionary signage. The Infection Preventionist (IP) stated that staff were informed of isolation precautions through in-service training, huddles, and posted signs. However, the observations and interviews demonstrated that these measures were not effectively communicated or adhered to, leading to a breach in infection control practices. This deficiency involved three of the five sampled residents, posing a risk for the transmission of disease-causing microorganisms.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance to residents in need of activities of daily living (ADL) care, particularly during night shifts. Resident 7 reported waiting 30 to 45 minutes for call lights to be answered, with her roommate experiencing a delay of over two hours for bathroom assistance. Similarly, Resident 8 had to wait over two hours for help to use the restroom, ultimately resorting to self-assistance via wheelchair. These delays in responding to call lights were corroborated by observations of staff behavior, where call lights were left unanswered while staff were present at the nursing station. Interviews with Certified Nursing Assistants (CNAs) revealed that residents were often found in soiled briefs and bed pads at the start of morning shifts, indicating a lack of care during the night. CNA 2 and CNA 3 both reported that residents were not clean upon their arrival, with CNA 2 noting that she had informed the charge nurse of this issue without any change. CNA 4 confirmed that it was common for morning CNAs to find residents dirty from the previous night shift, and the buddy system intended to ensure coverage was not being effectively utilized. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) acknowledged the issue, with the LVN stating that staff were expected to answer call lights within five minutes, yet it was common for staff to remain seated at the nursing station without responding. The ADON did not believe the facility had a staffing shortage but rather a performance issue among staff. The ADON verified the findings of the survey, indicating a systemic problem in the facility's response to resident needs.
Failure to Prevent and Address Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure ulcers for a resident. The resident, who was not capable of making medical decisions, was admitted and later discharged to an acute care hospital. The facility did not notify the resident's responsible party (RP) about changes in the resident's skin condition on two occasions. Additionally, the facility did not develop or implement a care plan addressing multiple changes in the resident's skin condition, including a fluid-filled blister and non-blanchable redness on the resident's feet. The facility's policy and procedure for pressure injury risk assessment and comprehensive person-centered care plans were not followed. The care plan intervention to float the resident's heels while in bed was also not adhered to. These failures were verified and acknowledged by a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) during interviews and medical record reviews.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for two residents. For Resident 2, the facility did not complete a discharge skin assessment for a Stage 2 pressure injury on the coccyx. Despite the injury being documented on 9/30/24, the discharge skin assessment form was left blank, and multiple staff members confirmed the absence of documentation upon discharge. This oversight indicates a lapse in the facility's protocol for documenting and managing pressure injuries at the time of discharge. For Resident 3, the facility did not ensure that a low air loss mattress, prescribed as a pressure-relieving device for an unstageable pressure injury on the sacrum, was plugged in and operational. During an observation, it was found that the mattress was unplugged, and the device lacked a backup battery, rendering it non-functional when not connected to a power source. The Director of Staff Development confirmed the device's dependency on being plugged in, and the facility's administration acknowledged these findings.
Incomplete Medical Documentation for Resident Care
Penalty
Summary
The facility failed to ensure complete and accurate medical documentation for a resident, which had the potential to result in inadequate care. The resident had a care plan for pressure ulcers related to impaired mobility and incontinence, requiring interventions such as turning and repositioning every two hours and checking for incontinence. However, documentation from September 14 to September 18 showed incomplete records for bladder and bowel incontinence, and on October 5, there was incomplete documentation for turning and repositioning between 1500 and 2200 hours. Additionally, there were discrepancies in the documentation related to the resident's Foley catheter care. The physician's orders required Foley catheter care every shift, but progress notes indicated the catheter was removed on September 26. Despite this, the treatment administration record (TAR) showed staff initials indicating the task was completed on dates after the catheter was removed. Interviews with the ADON and DSD confirmed the incomplete documentation and discrepancies in the TAR, which were acknowledged by the Administrator and ADON.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 5, which had the potential to delay the provision of assistance. The facility's policy and procedure, revised in September 2022, required that the call light be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor, and that the resident call system be answered immediately. On October 17, 2024, during an observation and interview with a Certified Nursing Assistant (CNA), it was noted that Resident 5 was calling for help, and the call light was observed on top of the pillow, out of the resident's reach. The CNA confirmed that the call light was not accessible to the resident. On October 24, 2024, the Administrator and Assistant Director of Nursing (ADON) acknowledged these findings.
Deficiency in Protecting Resident's Personal Property
Penalty
Summary
The facility failed to ensure the protection of personal property from theft or loss for one of the three sampled residents. This deficiency was identified during an abbreviated survey conducted by the California Department of Public Health. The survey focused on specific complaints and facility-reported incidents. Although no deficiencies were found for the specific complaint and incident numbers, an additional deficiency was cited under F584, which pertains to the resident's right to a safe, clean, comfortable, and homelike environment. The deficiency involved Resident 3, who was admitted to the facility and later discharged. Upon reviewing the facility's policy and procedure for discharging residents, it was found that the personal effects inventory was not properly reviewed and signed off by the resident or responsible party and the discharging nurse. The Clothing and Possessions form for Resident 3 showed that several personal items were listed upon admission, but the discharge section lacked signatures, indicating that the items were not verified as returned. Interviews with RN 1 and the DON confirmed that the process was not followed, leading to the potential for the resident's property to be lost or stolen.
Failure to Provide TV Remote Controls
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents, specifically regarding the availability of TV remote controls. During a facility tour and interview with the Maintenance Director, it was observed that Resident 5 was lying in bed, awake, and expressed boredom due to the TV not working because of the absence of a remote control. Resident B, who was sitting in her wheelchair, stated that she wanted to watch TV at night to keep up with the news but was unable to do so because there was no remote control, despite informing the nurse about the issue. Similarly, Resident E, also in a wheelchair, mentioned that his TV was not working and that he had informed the nurse but had given up after no action was taken. The Maintenance Director confirmed that each bed should have a remote control for the TV, verifying the deficiency in accommodating the residents' needs.
Failure to Conduct Required Skin Assessments
Penalty
Summary
The facility failed to complete the required weekly and discharge skin assessments for a resident, which was a deviation from their policy and procedure for the prevention of pressure injuries. The resident, who had multiple skin issues including diabetic ulcers, skin discoloration, and moisture-associated skin damage, was admitted and later discharged without the necessary skin assessments being documented. The facility's policy required comprehensive skin evaluations upon admission, weekly, and prior to discharge, but these were not performed for the resident in question. Interviews with the LVN and the DON confirmed that the assessments were not completed as required. The LVN, who was responsible for wound treatment, acknowledged that the weekly and discharge assessments were missed and could not account for the absence of wound photographs and documentation. The DON also verified that the necessary wound assessments were not conducted, indicating a lapse in following the facility's established procedures for skin care management.
Failure to Obtain Informed Consent for Medication Changes
Penalty
Summary
The facility failed to ensure that a resident was informed of changes in the dosage of their psychotropic medications, specifically amitriptyline and sertraline. The resident, who had the capacity to understand and make decisions, was not informed of the decrease in dosage of these medications, nor was informed consent obtained prior to administering an increased dosage. This oversight was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The medical records showed that the resident's medication orders were changed, increasing the dosage of amitriptyline and sertraline, but there was no documented evidence that informed consent was obtained for these changes. Interviews with the QA Nurse and the DON confirmed that the resident was receiving the increased dosages without having been informed or having provided consent. This failure had the potential to leave the resident uninformed about their medications and their potential side effects.
Failure to Include Residents in Care Planning Meetings
Penalty
Summary
The facility failed to ensure that two residents were invited to participate in their interdisciplinary team (IDT) behavior management conferences, which is a requirement according to the facility's policy and procedure (P&P) titled Care Planning - Interdisciplinary Team dated March 2022. This policy encourages residents to participate in the development and revisions of their care plans. Resident 1, who was admitted to the facility and had the capacity to understand and make decisions as per their history and physical examination dated February 17, 2023, was not documented as being encouraged to participate in IDT meetings held on December 7, 2023, and February 22, 2024. The Assistant Director of Nursing (ADON) confirmed that Resident 1 did not participate in these meetings and acknowledged that they should have been encouraged to do so. Similarly, Resident 2, who was admitted to the facility and had no cognitive impairment according to their Minimum Data Set (MDS), was also not documented as being encouraged to participate in IDT meetings held on January 11, 2024, and April 4, 2024. The Director of Nursing (DON) verified that Resident 2 did not participate in these meetings and stated that they should have been encouraged to participate. The lack of resident participation in these care planning meetings indicates a failure to adhere to the facility's policy, potentially impacting the residents' ability to choose their treatment options and make decisions regarding their care planning.
Infection Control Lapses in Personal Belongings and Equipment Storage
Penalty
Summary
The facility failed to implement proper infection control practices, leading to potential cross-contamination and disease transmission. During an observation, a licensed nurse was found to have placed personal belongings, including a black jacket and a bottle of water, on top of the treatment cart. The nurse confirmed these items were hers and admitted she was not informed about the prohibition of personal items on the treatment cart. The Director of Nursing (DON) acknowledged the issue and was unable to provide a policy and procedure related to this specific infection control measure. Additionally, a resident's nasal cannula was observed lying on the floor, which was verified by an LVN. The LVN stated that the nasal cannula should have been stored in a clean bag for infection control purposes, rather than being left on the floor.
Facility Fails to Provide Quality Care for Three Residents
Penalty
Summary
The facility failed to provide quality care for three residents, leading to several deficiencies. For Resident 8, the facility did not assess, notify the physician, or document a change of condition after an unwitnessed fall. Additionally, the facility did not complete neurological monitoring after a fall with a head injury for both Resident 8 and Resident 9. Resident 8 also experienced low oxygen saturation levels, and the facility failed to notify the physician. Furthermore, Resident 4 underwent a manual fecal disimpaction without a physician's order, and the facility did not administer PRN bowel movement medications as ordered for Resident 4. Resident 8 was found lying on a mattress on the ground next to his bed, but there was no documentation of the fall, and the physician was not notified. The facility's policy required assessment and documentation of falls, including vital signs, neurological status, and pain. However, these steps were not followed. Additionally, Resident 8's neurological checks after a fall were incomplete, with missing documentation for several intervals. Similarly, Resident 9's neurological checks after an unwitnessed fall were not fully completed, with several assessments marked as unnecessary. Resident 8 also had low oxygen saturation levels recorded, but there was no documentation of rechecking the levels or notifying the physician. For Resident 4, a manual fecal disimpaction was performed without a physician's order, and there was no documentation of the procedure. Resident 4 also did not receive PRN bowel movement medications as ordered, despite not having a bowel movement for several days. The facility's policies required physician notification and documentation for such procedures and medications, but these were not followed.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure that Resident 9 remained free from accident hazards by not implementing floor mats as per the physician's order and the resident's plan of care. On multiple observations on 5/14/24, Resident 9 was seen in bed without the required floor mats. The medical record review showed a physician's order dated 2/20/24, to apply floor mats every shift for fall precautions, and the resident's care plan also indicated the need for floor mats due to the resident's risk for falls related to lack of safety awareness, history of falls, and cognitive deficit. Despite these documented requirements, the floor mats were not in place during the observations made by the surveyors. LVN 1 confirmed the absence of floor mats and acknowledged the findings during an interview and concurrent medical record review. The Director of Nursing (DON) also acknowledged the findings and stated that she expected staff to carry out physician's orders. Resident 9 was admitted to the facility on an unspecified date and readmitted on another unspecified date. The resident had a documented history of falls and cognitive deficits, which necessitated the use of floor mats as a preventive measure. Despite these documented needs, the facility staff failed to implement the necessary safety interventions, thereby placing the resident at risk for serious injury. The deficiency was confirmed through observations, interviews, and medical record reviews conducted by the surveyors.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that Resident 8 was free from unnecessary drugs. Licensed nurses administered midodrine, a medication for blood pressure support, outside of the physician's ordered parameters. Specifically, the medication was given when the resident's systolic blood pressure (SBP) was greater than 130 mmHg, which was against the physician's order to hold the medication if SBP exceeded this threshold. This occurred on two occasions: on 4/26/24 at 1400 hours when the resident's BP was 131/80 mmHg, and on 4/27/24 at 2000 hours when the BP was 132/78 mmHg. The facility's policy and procedure (P&P) for administering medications, revised in April 2019, mandates that medications be administered in accordance with prescriber orders, including any required time frame, and that vital signs be checked if necessary. During an interview and concurrent medical record review on 5/14/24, LVN 7 verified that the medication should have been held as per the physician's order. The Director of Nursing (DON) was informed and acknowledged that the doses should not have been administered with the ordered parameters.
Failure to Develop and Implement CPAP Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan to address the use of a CPAP machine for one of the sampled residents. Resident 8, who had a diagnosis of obstructive sleep apnea, was admitted to the facility and had physician's orders for CPAP use at night and as needed for respiratory distress. The orders also included instructions for the type of mask, cleaning procedures, and replacement of mask tubing accessories. However, the resident's care plan did not include any problem addressing the use of the CPAP machine at bedtime, which is necessary for providing individualized care. During an interview and concurrent medical record review, an LVN confirmed that Resident 8 used the CPAP machine nightly and that the nurse on the 1500-to-2300-hour shift was responsible for applying it, while the LVN removed it at 0600 hours every morning. The LVN verified that the care plan should have included the CPAP use to ensure appropriate and consistent care. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that medications were administered as ordered for one resident. Specifically, Resident 1's sevelamer carbonate, a medication used to lower phosphorus levels, was not administered on hemodialysis days (Tuesdays, Thursdays, and Saturdays) at the prescribed time of 1230 hours. This failure was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). The facility's P&P required documentation of medication administration, including reasons for withholding or not administering medications, and specified that medications should be administered within one hour of their prescribed time unless otherwise specified. However, there was no documentation indicating that Resident 1 was re-offered the medication after returning from dialysis. Medical record reviews showed that Resident 1 had physician orders for hemodialysis on specific days and times, and for sevelamer carbonate to be administered three times daily. Despite these orders, the medication was not administered at 1230 hours on multiple occasions when Resident 1 was out of the facility for dialysis. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN) confirmed that Resident 1 was not in the facility at the scheduled medication time and that there was no documentation of re-offering the medication. The LVN acknowledged the need to clarify the physician's orders regarding the missed doses when the resident was not in the facility during dialysis days.
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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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