Solano Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Vallejo, California.
- Location
- 2200 Tuolumne Street, Vallejo, California 94589
- CMS Provider Number
- 056238
- Inspections on file
- 66
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Solano Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and pest-free environment when multiple flies were observed in several resident rooms, including a shared room occupied by three residents with dementia, depression, muscle weakness, and communication difficulties. Surveyors observed flies on privacy curtains, walls, bedding, a pillowcase, a resident’s gown, a sandwich and its wrapper, a phone, a drinking cup, and in the air around residents, along with a thick dried yellow substance on one resident’s sheets, bedframe, and pooled on the floor. One resident reported that bugs were "everywhere" and another was seen waving flies away from his face, stating they had been present for a while and that they bothered him. A CNA, the housekeeping manager, the ADM, the IP, and the ADON all confirmed the presence of flies and acknowledged that the conditions did not meet expectations for a safe, clean, and dignified environment, contrary to the facility’s infection control, pest control, homelike environment, and resident rights policies.
A resident with hemiplegia and dysarthria reported inappropriate touching by another resident and a staff member, but the facility did not report the alleged abuse to the state agency within the required two-hour timeframe. Staff interviews and documentation confirmed the delay, and the resident expressed feeling ignored and disappointed by the lack of urgency.
A resident with paralysis and speech difficulties reported being inappropriately touched by another resident and a staff member. The facility did not complete or report the required abuse investigations within the five-day timeframe outlined in policy, resulting in delayed action and the resident feeling ignored and distressed. Staff interviews confirmed the delay and awareness of reporting protocols.
A resident with schizophrenia and a history of delusions eloped from the facility without staff knowledge or authorization. Despite a care plan identifying behavioral risks and interventions, the resident was able to leave unsupervised. Staff interviews confirmed a lack of awareness regarding the resident's absence, and facility policy requiring supervision for at-risk residents was not effectively followed.
A nurse administered a resident’s scheduled medications four hours late, disposed of a refused medication in the trash instead of the approved disposal system, and inaccurately documented that all medications were given on time. Facility leadership confirmed the nurse did not follow physician orders or facility policy, and the MAR showed discrepancies in medication administration and documentation.
A facility failed to report an injury of unknown source within the required timeframe for a resident who sustained a broken left wrist. The incident was reported to the CDPH the day after it occurred. The DON and ADM were unaware that such injuries should be reported within two hours if they result in serious bodily harm, as per the facility's policy.
The facility failed to label clothing for two residents, risking the loss of personal possessions. A resident reported missing clothing after laundry, and staff confirmed the issue of unlabeled clothing. Observations revealed unlabeled clothing for another resident. Facility policies require labeling to ensure respect and dignity.
A resident was found with unattended medications, including controlled substances, on their bedside table. The resident, who was cognitively intact, reported that nurses had been leaving medications without supervision. The facility's policy requires staff to observe residents taking medications, which was not followed.
A facility failed to implement proper infection control practices when an LPN did not perform hand hygiene after leaving a resident's room. The LPN placed medication bubble packs on the resident's bed, compared them with medication cups, and returned the packs to the medication cart without hand hygiene, increasing the risk of infection spread. The DON confirmed the breach of protocol, which violated the facility's policies on hand hygiene and medication administration.
Staff failed to follow infection prevention protocols by removing gloves and gowns in the hallway after exiting a droplet isolation room, not changing N95 masks after leaving the room, and providing care to a COVID-19 positive resident without eye protection, all in violation of facility PPE policies.
A resident with severe cognitive impairment and multiple diagnoses refused ordered blood draws and diagnostic tests, but the physician was not notified as required by facility policy. The DON confirmed that the physician had not been informed, resulting in a lack of proper medical supervision for the resident.
A resident with multiple chronic conditions and severe cognitive impairment did not receive physician-ordered laboratory tests on two occasions. The facility lacked documentation or results for these tests, and the DON was unable to confirm if the tests were ever performed. This failure was confirmed through record review and interviews, despite facility policy requiring completion and reporting of all ordered labs.
A resident with congestive heart failure did not receive her prescribed diuretic medication for several days and was not informed of changes to her medication regimen. The resident experienced shortness of breath and anxiety due to the lack of communication and missed doses. The facility's policies on medication administration and resident notification were not followed, as confirmed by the nurse practitioner and Director of Nursing.
A resident with severe medical conditions had an IVCL dressing that was not changed as per the physician's order and facility policy, which required a change every 7 days. Multiple licensed nurses administered antibiotics through the IVCL without checking or changing the dressing, and the Director of Nursing confirmed the expectation for regular dressing changes to prevent infection.
A facility failed to properly discard a used syringe, which was left on a resident's bedside table. The resident, who was cognitively intact and had serious medical conditions, received an injection from a nurse who admitted to not disposing of the syringe in the sharps container. The DON confirmed that the expectation is for nurses to discard used syringes in sharps containers, as outlined in the facility's policy.
A facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating their needs. A resident with Parkinson's Disease and legal blindness, another with hemiplegia, and two others with cognitive impairments and fall risks were unable to access their call lights. Staff confirmed the call lights were not within reach, contrary to facility policies.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen therapy administration. A resident with COPD did not receive oxygen as ordered, resulting in shortness of breath. Another resident with acute respiratory failure was observed without the nasal cannula properly placed, risking low oxygen levels. A third resident with pneumonitis and congestive heart failure used a nasal cannula incorrectly and lacked an active physician's order for oxygen therapy.
The facility failed to ensure safe pharmaceutical services, with issues in controlled drug documentation, administration of expired medications, and improper storage of hazardous drugs. A resident missed cancer medication doses due to unavailability, and staff did not follow up with the pharmacy or notify the doctor. These deficiencies could lead to drug diversion and compromised resident care.
The facility failed to properly label and store medications, leading to the presence of loose pills, expired medications, and unlabeled opened medications in various medication carts. This resulted in the administration of expired medications to two residents and posed potential risks to others. Licensed nurses and the consultant pharmacist confirmed these deficiencies, which were not in accordance with the facility's policies and procedures.
A facility failed to ensure meal tray tickets matched the meals served to 11 residents, impacting their nutritional status and preferences. Despite documented dislikes for pork, residents were served pork loin, which was confirmed by the Dietary Manager Assistant. The residents had various medical conditions requiring dietary attention, and the facility's policy mandates meals consistent with resident preferences.
The facility failed to provide meals at appropriate temperatures and times, leading to resident dissatisfaction. Multiple residents reported receiving cold and late meals, particularly breakfast. Staff confirmed delays in meal service, and temperature checks showed food was not within recommended ranges. The facility's policies on meal service were not followed, impacting residents with chronic conditions.
The facility failed to comply with food safety standards, as staff did not wear hair nets or perform hand hygiene upon entering the kitchen. Additionally, expired food products were found in storage, posing a risk of foodborne illness to residents. The facility lacked a policy for handling expired food.
A long-term care facility failed to implement proper infection control measures, including the use of PPE by housekeeping staff, proper handling of linens, labeling and storage of urinals, and sanitization of shared medical equipment. These deficiencies were observed during a survey, highlighting potential risks for infection spread among residents.
The facility failed to document an injury for a resident with Alzheimer's and did not initiate physical therapy for another resident with muscle weakness and cerebral palsy. The injury was reported by family but not documented by an LPN, and the necessary insurance authorization for therapy was not obtained, leading to unmet nursing needs and potential decline in resident conditions.
A facility failed to ensure an accurate MDS assessment for a resident who was on oxygen therapy. The resident, admitted with conditions like pneumonitis and congestive heart failure, was inaccurately documented as not receiving oxygen therapy in the MDS assessment. This discrepancy was confirmed by the MDS Coordinator and noted by the DON, who both emphasized the importance of accurate assessments.
The facility failed to accommodate the beverage preferences of two residents. One resident, with diabetes and muscle weakness, was not served coffee during breakfast despite it being on the meal ticket. Another resident, with diabetes and Alzheimer's, preferred decaf coffee, which the facility did not provide. Staff acknowledged these preferences but did not fulfill them, citing reasons such as cost and lack of awareness.
The facility failed to maintain a clean environment for two residents, as their room had soiled privacy curtains and dirty windows. The residents reported infrequent cleaning, and the Resident Council's minutes noted similar complaints. Despite claims of daily cleaning, logs showed the room was last cleaned a week prior. The administrator could not provide a housekeeping policy.
The facility failed to report an abuse allegation involving a CNA and a resident within the required two-hour timeframe and did not submit an investigative summary within five working days. The incident was reported late to the Department, potentially delaying the investigation. The Administrator confirmed the delay but could not explain the late reporting, which was against the facility's policy.
A resident with a history of stroke and falls was admitted to the facility without a completed Fall Risk Assessment, leading to a lack of personalized interventions to prevent falls. The resident later experienced an unwitnessed fall resulting in injury. The DON revealed that the nurse filled out the wrong form, omitting the necessary assessment.
A resident was hospitalized with sepsis due to the facility's failure to ensure staff were aware of and monitored for UTI symptoms. Despite a physician's order, the resident was not properly monitored, leading to severe sepsis. Interviews revealed staff lacked understanding of UTI and sepsis symptoms, contributing to the oversight. The facility's policies on change of condition and UTI management were not effectively implemented.
The facility failed to implement its smoking policy and ensure supervision for two residents, both of whom were required to have supervised smoking sessions with their smoking materials stored by staff. Despite this, the residents kept their own smoking materials and sometimes smoked without supervision, posing a safety hazard. Staff interviews confirmed the policy requirements, but inconsistencies in enforcement were reported.
A resident with multiple health issues missed a medical appointment due to the facility's failure to arrange transportation and communicate with the resident and her responsible party. Despite the facility's policy, staff did not ensure transportation was secured, and the Director of Nursing did not inform the resident's family about the inability to attend the appointment.
The facility failed to implement its smoking policy and ensure supervision for two residents who required it. Despite having a policy that mandates staff supervision and storage of smoking materials, both residents reported smoking unsupervised and keeping their own cigarettes and lighters. Staff interviews confirmed these actions were against policy and posed safety risks. The deficiency highlights a failure to adhere to established protocols, compromising resident safety.
A resident missed a medical appointment due to the facility's failure to arrange transportation and communicate effectively with the resident and her responsible party. Despite the resident's daughter providing appointment details, the information was not relayed to the appropriate staff, resulting in no transportation being arranged. The Director of Nursing did not inform the resident's daughter that the appointment was unnecessary, leading to a missed opportunity for medical assessment.
A resident with chronic kidney disease and other conditions experienced altered mental status, including confusion and hallucination, but the facility failed to notify the physician or conduct a urinalysis to rule out a UTI. Despite the facility's policy requiring immediate physician consultation for significant changes, staff did not monitor the resident's mental status or suspect a UTI, leading to the resident's hospitalization with sepsis, acute UTI, and delirium.
A resident reported rough treatment by a CNA, but the facility delayed reporting the abuse allegation to authorities and did not immediately suspend the alleged staff. Despite staff understanding the need for timely reporting and suspension, the facility failed to act according to its policy, resulting in a deficiency.
A resident with cognitive impairments eloped from a facility during a smoking session due to inadequate supervision. The Activity Department, responsible for supervising smokers, lacked a set schedule or assignment, and the Wander Guard alarm was disarmed, allowing the resident to leave unnoticed. The facility could not provide a policy on smoking supervision, highlighting a procedural gap.
The facility failed to arrange the appropriate mode of transportation for a resident who needed a consult with an OB/GYN due to vaginal bleeding. The transportation request form did not specify the need for a gurney, resulting in a missed appointment. Interviews revealed a lack of clarity and responsibility regarding transportation arrangements, leading to the deficiency.
The facility failed to document and investigate how a resident sustained bruising on her eye, nor did they notify the physician. Despite staff acknowledging the need for documentation and investigation, no root cause analysis or care plan was created, posing a safety risk to the resident.
The facility failed to ensure a resident's needs were anticipated and frequently needed items, such as water, were within reach, resulting in a fall that caused a small cut on the resident's left index finger. The resident had a history of chronic pain, a fracture of the left humerus, and repeated falls, and required assistance with activities of daily living. Staff interviews confirmed that fall prevention policies were not consistently followed, and the fall could have been prevented if the care plan had been properly implemented.
Failure to Maintain a Safe, Clean, and Pest-Free Resident Environment
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to provide a safe, sanitary, and homelike environment for multiple residents when flies were observed in several resident rooms. One resident with major depressive disorder, anxiety disorder, muscle weakness, and inability to walk reported that there were bugs "everywhere" in her room; surveyors observed a small fly on her privacy curtain, several small flies hovering in the air, and several flies on the wall. Another resident’s room contained several flies flying in the room, including one on the lid of a cup. In a shared room occupied by three residents with diagnoses including dementia, failure to thrive, major depressive disorder, need for assistance with personal care, difficulty communicating, muscle weakness, and lack of muscle coordination, surveyors observed extensive fly activity. One resident’s bed was unmade, with a small black fly on the pillowcase, multiple flies on the privacy curtain and wall, and a sandwich in plastic wrap on the bedside table that had multiple small flies on and inside the wrapper, as well as flies on the speaker end of his phone and on his drinking cup. Another resident in the same room was lying in bed on sheets and a bedframe with a thick yellow dried substance on the sheets, bed frame, and pooled on the floor; numerous small black flies were on his mattress, bed frame, wall, privacy curtain, and gown, with one on his pillowcase and multiple flies slowly flying around his head. A third resident in that shared room was lying in bed and unable to answer questions, while multiple small black flies were observed on the privacy curtain and flying around. Staff interviews confirmed the unsanitary conditions. A CNA and the Housekeeping Manager both acknowledged the presence of flies on multiple surfaces, including the sandwich and phone of one resident and the mattress and pillow of another, and stated that it was not supposed to be like that. The Administrator, when brought to the shared room, confirmed the presence of multiple flies and stated, "It should not be like this." The Infection Preventionist, after being shown pictures of the flies, stated that her expectation was for residents to have a safe and clean environment to prevent infections and that flies could cause GI and respiratory issues. The Assistant DON, after viewing pictures of flies on a resident’s bed and clothing and the dried tan liquid on his sheets and bedframe, stated she would not expect to see that in the facility and that it was not good for someone with depression or for anyone. These conditions were inconsistent with the facility’s written policies on infection prevention and control, pest control, homelike environment, and resident rights.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required two-hour timeframe after a resident reported inappropriate touching by another resident and a staff member. The resident, who had diagnoses including left and right hemiplegia and dysarthria but no memory impairment, informed the charge nurse that a male resident kissed her forehead while she was asleep and that an X-ray technician touched her inappropriately on her shoulder, forehead, and breast, and made inappropriate comments. Documentation showed that the report of suspected abuse was not received by the state agency until two days after the initial allegation was made to the charge nurse. Interviews with facility staff, including the administrator, CNA, and RN, confirmed that the resident reported the incident promptly and that facility policy required immediate reporting of abuse allegations, but this protocol was not followed. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency in the facility's response. The delay in reporting resulted in a delayed investigation of the allegations.
Failure to Timely Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to timely investigate and report the results of abuse allegations within five days as required by policy. A resident with left and right hemiplegia and dysarthria, but no memory impairment, reported to the charge nurse that another resident allegedly kissed her forehead while she was asleep and that a staff member, specifically an X-ray technician, touched her inappropriately on her shoulder, forehead, and breast, and called her beautiful. Documentation showed that the resident reported these incidents on 8/3/25, but the 5-day investigation letters for both the staff-to-resident and resident-to-resident allegations were not completed until 8/11/25, eight days after the initial report. Interviews confirmed that the administrator, who was the primary investigator, acknowledged the investigation was not conducted in a timely manner. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency from the facility. Staff interviews indicated awareness of the protocol to report and document abuse allegations promptly, and a CNA observed the resident crying after the incident. The facility's policy required a written report of the investigation findings to be provided to the appropriate agencies within five working days of the incident, which was not met in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia, who had a history of delusions and behavioral issues, eloped from the facility without staff knowledge or authorization. The resident's care plan, which was revised shortly before the incident, identified behavioral risks related to schizophrenia and included interventions to anticipate the resident's needs. Despite these measures, the resident was able to leave the premises unsupervised. Interviews with facility staff revealed that the receptionist noticed the resident was missing from the front patio and subsequently notified other staff, but was unsure how long the resident had been absent. The Director of Nursing acknowledged both the risk of elopement due to the resident's mental health condition and the facility's responsibility to provide adequate supervision. Review of facility policy confirmed that residents at risk for elopement should receive appropriate supervision in accordance with their care plan, which was not effectively implemented in this case.
Late Medication Administration, Improper Disposal, and Inaccurate Documentation
Penalty
Summary
A Licensed Nurse failed to follow facility policy and professional standards by administering a resident’s scheduled medications four hours late, improperly disposing of a refused medication, and inaccurately documenting medication administration. The nurse gave the resident her 8 a.m. and 9 a.m. medications at 1:40 p.m., and when the resident refused MiraLAX, the nurse disposed of it in the trash instead of using the designated drug disposal system. The nurse then documented in the Medication Administration Record (MAR) that all medications, including the refused MiraLAX, were given at the scheduled times, rather than reflecting the actual time of administration and the refusal. The resident involved had a medical history including rhabdomyolysis, bariatric surgery status, and hypomagnesemia, and was admitted in January 2025. Facility leadership, including the DON and ADON, confirmed that the nurse did not follow physician orders, failed to notify the physician of the refusal, and did not adhere to the facility’s medication disposal policy. Review of the MAR and interviews confirmed the discrepancies in documentation and medication handling.
Plan Of Correction
Services Provided Meet Professional Standards Corrective Action(s): On 04/24/2025, LN 1 had a discussion with Resident 1 regarding her medication time preferences and notified the physician, resulting in a change to the medication administration schedule. On 04/24/2025, the Assistant Director of Nursing initiated an eLenteract CIC to evaluate Resident 1 for any undesired effects of medications that were not given timely and notified the physician. On 04/24/2025, the Director of Nursing re-educated LN 1 regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. Identification of other residents at risk: On 04/24/2025, the Assistant Director of Nursing checked if any other residents did not receive medications at the scheduled time, and no other residents were affected by this deficiency. Systemic Changes: On 05/08/2025, the Director of Staff Development will re-educate staff regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. The Director of Staff Development or designee will weekly skills check the Licensed nurses for Medication Observation Pass, including discarding and destroying medications, until competency is met. Monitoring: The Director of Staff Development or designee will report the results of the Licensed Nurses' skills checks for Medication Observation Pass, including discarding and destroying medications, to the Director of Nursing for further intervention if needed. The Director of Staff Development will report the findings and trends of the Medication Observation Pass, including discarding and destroying medications, to the QAPI committee monthly for three months or until compliance is met. Compliance Date: 05/08/2025
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required timeframe for one of the five sampled residents, identified as Resident 2. The incident involved Resident 2 sustaining a broken left wrist on March 20, 2025, which was reported to the California Department of Public Health (CDPH) the following day, March 21, 2025. During an interview on March 28, 2025, the Director of Nursing (DON) and Administrator (ADM) admitted they were unaware that such an injury, resulting in serious bodily harm, should have been reported within two hours. A review of the facility's policy and procedure on abuse, neglect, exploitation, or misappropriation indicated that injuries of unknown source should be reported within two hours of occurrence if they result in serious bodily injury.
Failure to Label Residents' Clothing
Penalty
Summary
The facility failed to ensure respect and dignity for two residents by not labeling their clothing, which had the potential to result in the loss of their personal possessions. Resident 4, who was admitted in October 2024 and is cognitively intact, reported issues with clothing being lost after being sent to the facility laundry, specifically mentioning the loss of two pairs of grey sweatpants. During an interview, a Certified Nursing Assistant (CNA) acknowledged the issue of missing laundry when clothing was not labeled, and the Laundry Supervisor confirmed that clothing should be inventoried and labeled upon admission and when new clothes are brought in. Additionally, during observations, the Director of Staff Development (DSD) confirmed that several items of clothing belonging to Resident 7, who was admitted in December 2021 with osteoarthritis, were not labeled. The facility's policy and procedure on personal clothing, revised in June 2016, requires all clothing to be labeled and for staff to ensure that any clothing brought in by families is labeled properly. The facility's policy on Resident's Rights, dated February 2021, emphasizes the residents' rights to be treated with respect, kindness, and dignity.
Failure to Safely Administer Medications
Penalty
Summary
The facility failed to administer medications safely and in accordance with professional standards for one resident. The resident was found with unattended medications on his bedside table, which included controlled substances. The resident, who was cognitively intact and had no memory issues, reported that nurses had been leaving his medications without observing him take them. There were no care plans or physician orders allowing the resident to self-administer medications. Licensed Nurse 1 confirmed that she had provided the medications earlier and was supposed to supervise the resident taking them, but failed to do so. The Director of Nursing acknowledged that the resident had not been assessed for self-administration and that leaving medications unsupervised was unacceptable. The facility's policy requires medications to be administered according to prescriber orders and for staff to observe residents taking their medications, which was not followed in this instance.
Infection Control Breach Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey involving a licensed nurse (LN 1) and a resident. LN 1 did not perform hand hygiene after leaving a resident's room, which is a critical step in preventing the spread of infections. The incident occurred when LN 1 was administering medications to the resident. LN 1 placed medication bubble packs on the resident's bed and compared them with medication cups on the bedside table. After completing this task, LN 1 left the room without conducting hand hygiene and returned the medication bubble packs to the medication cart, acknowledging the increased risk of infection spread due to this action. The Director of Nursing (DON) confirmed that staff are required to perform hand hygiene upon exiting residents' rooms and acknowledged that returning medication packs that had been in contact with surfaces inside the resident's room to the medication cart posed a risk of cross-contamination. The facility's policies and procedures on administering medications and hand hygiene emphasize the importance of following infection control procedures, including handwashing before and after contact with residents and after contact with contaminated surfaces. The failure to adhere to these procedures decreased the facility's potential to prevent the spread of infections among residents.
Failure to Follow Droplet Isolation Precautions and PPE Protocols
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols for droplet isolation precautions. During observation, a housekeeping staff member exited a droplet isolation precaution room while still wearing an N95 mask, gown, and gloves, and then removed the used gloves and gown in the hallway where other staff and residents were present. The staff member confirmed awareness of the room's isolation status and acknowledged removing the PPE outside the room, contrary to facility policy, which requires removal and disposal of gloves and gowns before leaving the resident room or care area. Additionally, both the housekeeping staff and a certified nurse assistant (CNA) exited the same droplet isolation precaution room without changing their used N95 masks. Both staff members confirmed in interviews that they did not change their masks after leaving the room, despite facility policy stating that disposable respirators must be removed and discarded after exiting the resident's room or care area. Furthermore, the CNA entered the droplet isolation precaution room and assisted a resident who had tested positive for COVID-19 without wearing any eye protection, such as a face shield or goggles. The CNA confirmed this omission during an interview, and the infection preventionist and director of nursing both stated that eye protection is required when providing care to residents with confirmed COVID-19. Facility policy also specifies that eye protection must be applied upon entry to the resident room or care area.
Failure to Notify Physician of Resident's Refusal of Ordered Tests
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician after the resident refused a blood draw and diagnostic tests, despite having physician orders for these procedures. The resident, who had diagnoses including metabolic encephalopathy, diabetes mellitus, and dementia, was assessed as having severely impaired cognition with a BIMS score of 6 out of 15. The care plan required monitoring changes in cognitive status and notifying the physician as needed. However, documentation showed that while the resident's responsible party was informed of the refusals, there was no evidence that the physician was notified. The Director of Nursing confirmed during record review that the physician had not been informed of the resident's refusal of the ordered laboratory and diagnostic tests. Facility policy required the attending physician to be involved in monitoring changes in the resident's medical status and to be notified regarding care, diagnostic tests, and treatment. The lack of communication with the physician meant the resident's care was not properly supervised as required.
Failure to Complete and Document Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide quality and timely laboratory services for one resident when laboratory tests ordered on two separate occasions were not completed. The resident, who was admitted in January 2024, had multiple diagnoses including metabolic encephalopathy, diabetes mellitus, and dementia, and was assessed as having severely impaired cognition. Physician orders for a series of laboratory tests, including CBC, CMP, HBA1C, Vitamin D, TSH, and lipid panel, were documented on two dates, but there was no evidence in the clinical record or progress notes that these tests were performed or that results were obtained. During interviews, the responsible party confirmed that the resident's laboratory tests were not being done, and the DON acknowledged that the facility did not have the results and was unaware if the tests had been completed or why the results were missing. Facility policy required that all physician-ordered laboratory tests be completed and results reported to the physician, but this was not followed in this case.
Failure to Administer Diuretic Medication and Inform Resident of Changes
Penalty
Summary
The facility failed to provide quality care and treatment for a resident with congestive heart failure, who was not informed of changes to her diuretic medication and did not receive the medication as prescribed. The resident, who had intact cognition, was admitted with multiple diagnoses including congestive heart failure, which can cause leg swelling. The resident's care plan indicated that she should not experience signs of fluid overload, and her medication administration record showed she was to receive a diuretic twice daily. However, the resident did not receive her medication from February 14 to February 18, as evidenced by the lack of nurse initials on the medication administration record. The resident expressed anxiety over sudden medication changes and reported shortness of breath and wheezing. The nurse practitioner confirmed that the resident missed doses and that the medication should have been resumed after a temporary increase. The licensed nurse acknowledged receiving the new order but failed to document the changes or notify the resident. The Director of Nursing stated that licensed nurses are expected to ensure orders are correct, administered, and documented, and that residents are notified of medication changes. The facility's policies require documentation of physician orders, changes in condition, and notification of residents, which were not followed in this case.
Failure to Change IVCL Dressing as Ordered
Penalty
Summary
The facility failed to adhere to the physician's order for changing the dressing around an Intravenous Central Line (IVCL) every 7 days for a resident. The resident, who was admitted with severe medical conditions including necrotizing fasciitis, severe sepsis with septic shock, and gangrene, had an IVCL dressing that was not changed since the date of admission. This oversight was confirmed during an observation and interview with a licensed nurse, who acknowledged that the dressing should have been changed according to the facility's policy and procedure to prevent infection. Multiple licensed nurses administered antibiotics through the resident's IVCL without checking or changing the dressing, as required by the physician's order and facility policy. The Director of Nursing also confirmed the expectation for registered nurses to change the dressing every 7 days. The facility's policy clearly outlined the responsibility of licensed nurses to document and implement physician orders, including the timely change of IVCL dressings to prevent potential infections.
Failure to Properly Discard Used Syringe
Penalty
Summary
The facility failed to properly discard a used syringe for one of the residents, which was observed on the resident's bedside table. This incident involved a resident who was admitted with serious medical conditions, including necrotizing fasciitis, severe sepsis with septic shock, and gangrene. The resident was cognitively intact, as indicated by the Brief Interview for Mental Status (BIMS). During an observation and interview, a licensed nurse admitted to administering an injection to the resident and leaving the used syringe on the bedside table instead of discarding it in the designated sharps container. The Director of Nursing (DON) confirmed that the expectation for nurses is to dispose of used syringes in sharps containers. The facility's policy and procedure for subcutaneous injections, revised in March 2011, also specified that a sharps container should be used to discard uncapped needles and syringes. The failure to follow this procedure had the potential to cause injury to the resident and staff due to accidental needle sticks.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating their needs and preferences. Resident 11, who was legally blind and had Parkinson's Disease, was unable to locate or reach her call light on multiple occasions. Despite being a fall risk, her call light was either at the head of her bed or wrapped around the bed's side rail, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that Resident 11 could not see or reach the call light. Resident 96, who had hemiplegia affecting the left side of her body, was also unable to reach her call light, which was found on the floor next to her bed. She required substantial assistance with activities of daily living and had an impairment in upper and lower range of motion. During an observation, a CNA confirmed that the call light was not within Resident 96's reach, which was contrary to the facility's policy and procedure that emphasized the importance of having call lights within reach. Similarly, Resident 28 and Resident 234 experienced issues with inaccessible call lights. Resident 28, who had dementia and a history of falls, was found with her call light button on the floor, out of reach. Resident 234, with moderately impaired cognition and a history of falls, had his call light hanging on the back side of his bed, making it unreachable. Both residents expressed their inability to reach the call lights, and staff confirmed these observations. The facility's policies clearly stated that call lights should be within residents' reach, yet this was not adhered to, leading to the deficiency.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy administration. Resident 11, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), did not receive oxygen as ordered, resulting in shortness of breath. The resident's care plan required oxygen therapy at 2 liters per minute via nasal cannula, but during an observation, the resident was found without the nasal cannula and reported not receiving oxygen for the past 30 minutes. A Certified Nursing Assistant confirmed the absence of oxygen delivery, which contradicted the physician's orders and the facility's policy on oxygen administration. Resident 280, admitted with acute respiratory failure and severe cognitive impairment, was observed without the nasal cannula properly placed, despite being on continuous oxygen therapy as per physician orders. The nasal cannula was found under the resident's chin, and the Infection Preventionist confirmed the improper placement, acknowledging the risk of low oxygen levels and shortness of breath. The resident's care plan lacked documentation for oxygen therapy initiation upon admission, further highlighting the facility's oversight in ensuring proper respiratory care. Resident 254, with diagnoses including pneumonitis and congestive heart failure, was using a nasal cannula incorrectly, with the prongs not inserted into the nose. The resident had no active physician's order for oxygen therapy from the time of admission until the observation date. The Director of Nursing confirmed the absence of a physician's order and emphasized the necessity of having such orders as part of professional standards. The facility's policy required verification of a physician's order for oxygen therapy, which was not adhered to in this case.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by several deficiencies in medication management. Controlled drugs for two residents were not properly documented in their Medication Administration Records (MAR) after being signed out from the Controlled Drug Record (CDR), and another resident's controlled drug use was inaccurately recorded. This lack of documentation could lead to discrepancies in drug accountability and potential drug diversion. The Director of Staff Development and the Consultant Pharmacist confirmed these findings, emphasizing the importance of accurate documentation for controlled drug handling. Additionally, the facility administered expired medications to two residents. One resident received 15 doses of insulin past its discard date, while another resident received 16 doses of expired buspirone. The Licensed Nurses confirmed these observations during medication cart inspections, acknowledging that administering expired medications could negatively affect the residents' health. The facility's policies and procedures require the removal and disposal of outdated medications, but these were not followed, leading to the administration of ineffective medications. Furthermore, hazardous medications were stored without proper labeling, and a resident missed two doses of a critical cancer medication due to unavailability. Valproic Acid, a hazardous drug, was found without a warning label, which is necessary for safe handling by nursing staff. The Director of Nursing and the Consultant Pharmacist confirmed the need for proper labeling to ensure safety. Additionally, a resident's cancer medication was not administered for two days, and there was no documented follow-up with the pharmacy or notification to the doctor about the missed doses. This oversight could increase the resident's risk for infection and compromise their treatment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored according to their policies and procedures, as well as accepted professional principles. During inspections of various medication carts, surveyors found loose pills in the 100, 700, and 400-Odd Hallway medication carts. Licensed nurses confirmed the presence of these loose pills and acknowledged that they were unsure of the medications' identities, which posed a risk of diversion and potential harm to residents. Additionally, the facility did not adhere to proper storage protocols for insulin and other medications. Two opened insulin medications past their discard dates were found in the 100 Hallway medication cart, and an expired bubble pack of buspirone was discovered in the 300 Hallway medication cart. These expired medications were confirmed by licensed nurses and the consultant pharmacist as unsafe for administration to residents, yet they remained in the carts, leading to the administration of expired medications to residents. Furthermore, the facility failed to label medications with opened dates, which is crucial for determining when they should be discarded. Five eye medications, an insulin, and three semaglutide medications in the 300 Hallway medication cart lacked opened date labels. This oversight was confirmed by licensed nurses and the consultant pharmacist, who emphasized the importance of labeling to ensure medications are discarded after 28 days of opening. The facility's policies and procedures clearly outlined the need for proper labeling and storage, yet these were not followed, resulting in potential risks to resident safety.
Inaccurate Meal Tray Tickets Impact Resident Preferences
Penalty
Summary
The facility failed to ensure that meal tray tickets for 11 sampled residents were accurate and followed, which had the potential to negatively impact their nutritional status and meal preferences. During an observation and interview with the Dietary Manager Assistant (DMA), it was noted that the meal tray tickets did not match the meals served to the residents. Specifically, pork loin was served for lunch, despite all 11 residents having indicated a dislike for pork on their meal tray tickets. The DMA acknowledged that the facility's system had not been updated to reflect the correct meals on the tray tickets. The residents involved had various medical conditions, including hypertensive heart and chronic kidney disease, severe sepsis with septic shock, acute posthemorrhagic anemia, pulmonary hypertension, congestive heart failure, anemia, atherosclerotic heart disease, and spinal stenosis. These conditions necessitate careful attention to dietary preferences and restrictions to maintain their health. The failure to adhere to the meal tray tickets meant that the residents were not provided meals consistent with their documented preferences, which could potentially affect their health and well-being. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the meal tickets and the meals served should match. The facility's policy, titled 'Resident Food Preferences,' also indicated that the Dietary Department is responsible for providing meals consistent with residents' preferences as indicated on their tray cards. This discrepancy between the meal tickets and the meals served represents a deficiency in the facility's adherence to its own policies and procedures.
Deficiency in Meal Service Temperature and Timing
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food at preferred temperatures for eight residents. Residents reported that meals, particularly breakfast, were consistently served cold and late. Observations confirmed that food temperatures were below recommended levels, with hot foods being served cold and cold foods not being adequately chilled. This issue was corroborated by multiple residents and staff members, who noted dissatisfaction with the meal service. Several residents, including those with chronic conditions such as diabetes, chronic kidney disease, and end-stage renal disease, expressed dissatisfaction with the quality and temperature of the food. Interviews with residents revealed that meals were often served late, with breakfast sometimes arriving as late as 10 a.m., well past the scheduled meal service times. Staff members, including a Licensed Nurse and a Certified Nursing Assistant, confirmed that meal carts were frequently delayed, leading to complaints from residents about hunger and cold food. The Registered Dietician and Director of Nursing acknowledged the issues with meal service timing and food temperature, confirming that meals were not served according to the facility's policy and procedure. Temperature checks conducted during a test tray service further validated the residents' complaints, showing that food temperatures were not within the recommended range. The facility's policies on meal service times and food safety were not adhered to, contributing to the residents' dissatisfaction and potential health risks.
Non-compliance with Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several staff members, including the Maintenance Director, Registered Dietician, a food delivery driver, and the Dietary Manager Assistant, did not comply with the facility's policy on hygiene and sanitary practices. Specifically, these individuals entered the kitchen without wearing hair nets or performing hand hygiene, which is a requirement to prevent contamination and ensure infection control. The Maintenance Director and Registered Dietician acknowledged their failure to wash hands upon entering the kitchen, while the Dietary Manager Assistant confirmed that the delivery driver should have worn hair and facial hair nets. Additionally, the facility was found to have expired food products in both the walk-in freezer and dry storage room. Items such as mayonnaise, cilantro, corn meal, iced tea, and raisins were either unlabeled or past their expiration dates, posing a risk of foodborne illness to residents. The Dietary Manager Assistant admitted that these items should have been discarded and could not explain how the expiration dates were overlooked. The facility lacked a specific policy and procedure for handling expired food products, further contributing to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention measures, as evidenced by several observations. Housekeeping staff did not wear the required Personal Protective Equipment (PPE) when cleaning a room under Enhanced Barrier Precautions, despite clear signage and policy requirements. The housekeeper admitted to bypassing the sign and acknowledged the mistake. The Infection Preventionist confirmed that the expectation was for staff to wear PPE in such situations. Additionally, a Certified Nursing Assistant (CNA) was observed placing dirty linen into a clean linen storage closet, which could lead to cross-contamination. The CNA admitted to forgetting to use a plastic bag for the linens and confirmed the error. The Infection Preventionist highlighted the risk of microorganisms being transferred back to residents due to this oversight. Further deficiencies included the improper storage of urinals without labels or dates, posing a risk of cross-use among residents. Personal items were found stored in medication carts, which could contaminate medications. Lastly, a shared glucometer was not sanitized properly between uses on different residents, as it was not kept wet for the required two minutes with germicidal wipes. These actions collectively increased the potential for infection spread among the resident population.
Failure to Document Injury and Initiate Physical Therapy
Penalty
Summary
The facility failed to ensure that Resident 103 received care meeting professional standards when an injury of unknown origin was reported by the family but not documented in the nursing notes until the following day. Resident 103, who was admitted with Alzheimer's Disease and severe memory impairment, had a bruise on her right forearm that was not documented in the body check assessment or weekly summary by Licensed Nurse 2 (LN 2). The Director of Nursing (DON) acknowledged that the bruise was a change of condition that should have been documented and communicated to the family and physician, as per the facility's policy. Additionally, the facility did not obtain authorization for physical therapy treatment for Resident 97, who was admitted with multiple diagnoses including muscle weakness and cerebral palsy. Despite a physician's order for physical therapy due to weakness, the therapy was not initiated because the facility failed to follow up on obtaining the necessary insurance authorization. The physical therapist confirmed that Resident 97 was not on the therapy caseload, and the Clinical Coordinator (CC) admitted that the facility did not follow up on the order, resulting in the resident not receiving the needed therapy. These failures resulted in inaccurate assessment documentation for Resident 103 and had the potential to result in unmet nursing needs. For Resident 97, the lack of physical therapy had the potential to cause a decline in activities of daily living and worsening weakness, as the resident expressed concern about becoming bedbound without continued activity. The facility's policies on skin integrity management and notification of change of condition were not adhered to, leading to these deficiencies.
Inaccurate MDS Assessment for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 254, upon admission. The resident was admitted in November 2024 with several diagnoses, including pneumonitis, hemiplegia, hemiparesis, and congestive heart failure. Despite being on oxygen therapy at 2 liters per minute via nasal cannula, the resident's MDS assessment inaccurately indicated that the resident did not receive oxygen therapy upon admission or while residing in the facility. The inaccuracy was confirmed during a review of the resident's clinical records and an interview with the MDS Coordinator, who acknowledged the mistake and stated that MDS assessments should accurately reflect the resident's status. The Director of Nursing also emphasized the expectation for timely and accurate MDS assessments. The facility's policy on resident assessments, revised in October 2023, mandates that MDS assessments consistently reflect information in progress notes, care plans, and resident observations or interviews.
Failure to Accommodate Resident Beverage Preferences
Penalty
Summary
The facility failed to provide food that accommodates the needs and preferences of two residents. Resident 130, who was admitted in November 2024 with diagnoses including diabetes mellitus and muscle weakness, was not served coffee during a breakfast meal despite it being listed on his meal ticket. Resident 130, who had intact cognition, expressed frustration over not receiving coffee consistently, which was confirmed by a Licensed Nurse and the Director of Nursing, both acknowledging that coffee should have been served as per the meal ticket. Resident 240, admitted in November 2024 with diagnoses including diabetes mellitus and Alzheimer's disease, expressed a preference for decaffeinated coffee, which the facility did not provide. The resident, with moderately impaired cognition, had informed staff of this preference, but the facility only served regular coffee. The Registered Dietician was aware of the preference but was unsure if decaf coffee had been ordered. The Dietary Manager Assistant was unaware of the preference and cited cost as a reason for not ordering decaf coffee, despite acknowledging that resident preferences should be honored.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Residents 2 and 3, as evidenced by soiled privacy curtains and dirty windows in their shared room. Resident 2 reported that their room was not cleaned daily, and they were fortunate if it was cleaned twice a week. Both residents confirmed the lack of regular cleaning, and Resident 2 noted that the privacy curtains had not been washed in months. The Resident Council's minutes from August 2024 also documented complaints about room cleanliness. Despite the Housekeeping Director's claim that rooms were cleaned daily, logs showed that the last cleaning for Residents 2 and 3's room occurred on 8/23/24. The facility's administrator was unable to provide a housekeeping policy and procedure when requested.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Department and did not submit an investigative summary within five working days. The incident involved a Certified Nursing Assistant (CNA) verbally abusing a resident on October 12, 2023. The facility became aware of the abuse allegation on the same day but reported the incident to the Department via voicemail on October 14, 2023, and faxed the SOC 341 form on October 16, 2023. This delay in reporting had the potential to hinder the Department's timely investigation of the abuse allegation. Furthermore, the facility's investigative report, dated October 20, 2023, was not faxed to the Department until October 25, 2023. During interviews conducted on August 29 and 30, 2024, the Administrator confirmed the details of the SOC 341 and the investigative report but could not provide an explanation for the late reporting and submission. The facility's policy, dated February 23, 2021, clearly stated that all allegations of abuse should be reported within two hours and an investigative report submitted within five working days, which was not adhered to in this case.
Failure to Complete Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to complete a Fall Risk Assessment for one of the residents prior to developing interventions to reduce the risk of falls. This deficiency was identified during a review of the facility's records and interviews with staff. The resident in question was admitted to the facility with a history of stroke, encephalopathy, previous falls, and difficulty walking, which necessitated assistance with personal care. Despite these conditions, no Fall Risk Assessment was completed for the resident, which is a critical step in identifying appropriate interventions to prevent falls. The deficiency was discovered after the resident experienced an unwitnessed fall, resulting in an injury that required hospital evaluation. During an interview, the DON explained that the nurse responsible for the resident's admission mistakenly filled out the wrong report form, omitting the necessary Fall Risk Assessment. The facility's policy mandates that fall risk assessments be conducted upon admission and after any fall incidents, but this protocol was not followed in this case, leading to a lack of personalized fall prevention strategies for the resident.
Failure to Monitor and Recognize UTI and Sepsis Symptoms
Penalty
Summary
The facility failed to ensure that staff were adequately trained and aware of the symptoms and risks associated with sepsis and urinary tract infections (UTIs). This deficiency was highlighted by the case of a resident who was hospitalized due to sepsis. The resident, who had intact cognition and required assistance with activities of daily living, was not properly monitored for signs and symptoms of a UTI, despite a physician's order to do so. The lack of monitoring and awareness among staff led to the resident developing severe sepsis, which was confirmed upon hospitalization. Interviews with various licensed staff members revealed a general lack of understanding and vigilance regarding the symptoms of UTIs and the progression to sepsis. Staff members acknowledged that some residents might not present with classic UTI symptoms, yet they failed to monitor residents closely for subtle changes in condition, such as altered mental status or general malaise. The staff's failure to recognize these signs and take appropriate action contributed to the resident's condition worsening to sepsis. The Director of Staff Development confirmed that the resident was transferred to the emergency department due to altered mental status and that no urinalysis was conducted to check for a UTI. The facility's policies on change of condition and UTI management were not effectively implemented, as evidenced by the lack of immediate consultation with a physician and failure to identify and treat the infection in a timely manner. The absence of a provided policy and procedure for sepsis further underscores the facility's deficiency in managing and preventing such critical conditions.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and follow the smoking interventions identified in the Smoking Risks Assessment form and smoking care plan for two residents. Both residents were required to have supervised smoking sessions, and their smoking materials were to be kept by the facility staff. However, it was observed that these protocols were not consistently followed, leading to a safety hazard. Resident 1, who has diagnoses including Bipolar disorder, Heart Failure, and COPD, was found to be keeping her own smoking materials and sometimes smoked without staff supervision, contrary to her care plan which required supervision and storage of smoking materials by the nursing station. Similarly, Resident 2, diagnosed with Multiple Sclerosis and Quadriplegia, also kept his own cigarettes and lighter and smoked without supervision, despite his care plan indicating the need for staff supervision and storage of smoking materials by the Social Services office. Interviews with various staff members, including licensed and unlicensed personnel, confirmed that the facility's policy required staff supervision during smoking and that residents were not allowed to keep their smoking materials. The Director of Nursing also confirmed these requirements. Despite this, both residents reported inconsistencies in supervision, and staff interviews revealed that the facility's smoking policy was not consistently enforced, posing a risk of accidents, burns, and injuries.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident attended her medical appointment, which was crucial for assessing her ongoing health issues. The resident, who had diagnoses including hyperlipidemia, major depression, and anxiety, required assistance with activities of daily living. Despite the facility's policy to arrange transportation for medical appointments, the resident and her responsible party were not informed that transportation could not be secured, leading to a missed appointment. Interviews with various staff members revealed a breakdown in communication and adherence to policy. Unlicensed staff and social services assistants confirmed that the facility was responsible for arranging transportation and notifying residents or their responsible parties if transportation could not be arranged. However, the social services assistant did not receive the necessary appointment information from the Director of Nursing (DON), resulting in no transportation being arranged for the resident's appointment. The DON acknowledged receiving the appointment information from the resident's daughter but failed to communicate this to the necessary parties or arrange transportation. Furthermore, the DON did not inform the resident's daughter that the appointment would not be attended due to transportation issues. This lack of communication and failure to follow the facility's policy led to the resident missing a potentially important medical appointment, which could have addressed her health concerns.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and follow the smoking interventions identified in the Smoking Risks Assessment form and smoking care plan for two residents. Resident 1, who has diagnoses of Bipolar disorder, Heart Failure, and Chronic Obstructive Pulmonary Disease, was assessed to require supervised smoking. However, she reported keeping her own smoking materials and sometimes smoking without staff supervision, contrary to the facility's policy. Similarly, Resident 2, diagnosed with Multiple Sclerosis, Quadriplegia, and Muscle Weakness, also required supervised smoking but admitted to keeping his own cigarettes and lighter and smoking without supervision at times. Interviews with various staff members, including licensed and unlicensed staff, confirmed that the facility's policy required residents to be supervised while smoking and that smoking materials should be kept by the staff. Despite this, both residents reported instances where they smoked unsupervised and retained their smoking materials, indicating a failure to adhere to the policy. Staff members acknowledged that these actions were against the facility's policy and posed safety risks, including potential accidents, burns, and injuries. The Director of Nursing and other staff confirmed the facility's responsibility to supervise residents during smoking and to keep their smoking materials for safety reasons. The facility's policy, effective since August 2022, emphasized the need for reasonable precautions and a safe environment for residents who smoke, including individualized plans for safe storage and supervision. The failure to follow these protocols was identified as a deficiency, posing a safety hazard to the residents involved.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that Resident 1 attended her medical appointment, which was crucial for assessing her ongoing health issues, including bouts of diarrhea. Despite the resident's daughter providing the appointment details to the Director of Nursing (DON), the information was not effectively communicated to the Social Services Assistant responsible for arranging transportation. As a result, no transportation was arranged, and the resident missed her appointment. Interviews with various staff members, including unlicensed staff, social services assistants, and licensed staff, revealed a lack of communication and adherence to the facility's policy regarding transportation arrangements. Staff members acknowledged that the facility should have arranged transportation and communicated any issues to the resident or her responsible party (RP). However, this did not occur, leading to the resident missing her medical appointment. The DON admitted to receiving the appointment information but failed to communicate it effectively to ensure transportation was arranged. Furthermore, the DON did not inform the resident's daughter that the appointment was deemed unnecessary due to the resident's status as a [Medical Organization] recipient. This lack of communication and failure to arrange transportation resulted in the resident missing a potentially important medical assessment, which could have addressed her symptoms and prevented them from worsening.
Failure to Notify Physician and Conduct Urinalysis for Resident with Altered Mental Status
Penalty
Summary
The facility failed to adhere to its Change of Condition policy and professional standards of practice in diagnosing a Urinary Tract Infection (UTI) for a resident, leading to a significant health decline. The resident, who had a history of chronic kidney disease, hyperlipidemia, and depression, exhibited altered mental status, including confusion, hallucination, and agitation. Despite these symptoms, the facility staff did not immediately notify the physician or conduct a urinalysis to rule out a UTI, which is a standard procedure for such symptoms. Interviews with licensed staff revealed that the resident's confusion and hallucination were new symptoms, yet there was no documentation indicating that the physician was notified of these changes. The staff confirmed that they were not monitoring the resident's mental status for several days and did not suspect a UTI, despite the resident's acute change in condition. The facility's policy required immediate consultation with a physician for significant changes in a resident's physical, mental, or psychosocial status, which was not followed in this case. The resident was eventually hospitalized with diagnoses of sepsis, acute UTI, and delirium. The facility's failure to monitor the resident's mental status and notify the physician of the change in condition resulted in a delay in treatment. The facility's policy on urinary tract infections also emphasized the importance of identifying signs and symptoms of a UTI, which was not adhered to, contributing to the resident's hospitalization.
Failure to Timely Report and Act on Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner for one resident, leading to a deficiency in their abuse reporting protocol. The resident, who had intact cognition and required assistance with activities of daily living, reported that a CNA was rough during care. Despite the report being made on a Sunday, the facility did not notify the appropriate agencies until the following day. This delay in reporting was acknowledged by the Director of Nursing and the Administrator, who confirmed that the abuse allegation was not reported until the next day. Additionally, the facility did not suspend the alleged staff member immediately after the abuse allegation was made, allowing the CNA to continue working until the next day. Interviews with various staff members, including licensed and unlicensed personnel, revealed a general understanding that abuse allegations should be reported within 24 hours and that the alleged staff should be suspended pending investigation. However, these procedures were not followed, as confirmed by the facility's policy, which mandates immediate removal of the alleged staff from duty and reporting of the incident within two hours.
Inadequate Supervision During Smoking Sessions Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision during resident smoking sessions, which led to a resident eloping from the facility. Resident 10, who had a history of chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, congestive heart failure, and moderate dementia, was admitted to the facility with a BIMS score indicating moderate to severe cognitive impairment. On a particular day, Resident 10 was found wandering with a cigarette wrapper on his lap, suggesting he had been smoking. Despite being considered for a Wander Guard due to his mental deficits, Resident 10 managed to elope from the facility grounds during a smoking session. The facility's Activity Department was responsible for supervising resident smokers, but there was no set schedule or assignment for supervision. Activity Assistant B, who often supervised smoking sessions, indicated that the Wander Guard alarm was disarmed during these sessions, which allowed Resident 10 to leave without triggering an alarm. On the day of the incident, Resident 10 walked through the patio area and left the facility grounds, later being found on a nearby street. The Assistant Director of Nursing confirmed that the alarms did not go off as expected when Resident 10 left, although they were functioning properly when tested afterward. Interviews with various staff members, including Activity Assistants and the Activity Director, revealed a lack of awareness and communication regarding Resident 10's elopement. The facility was unable to provide a policy on supervision during smoking sessions, indicating a gap in procedural guidelines. This lack of structured supervision and policy contributed to the resident's ability to elope, posing a potential risk to his safety.
Failure to Arrange Appropriate Transportation for Medical Appointment
Penalty
Summary
The facility failed to arrange the appropriate mode of transportation for Resident 1, who needed a consult with an OB/GYN due to vaginal bleeding. Physician A had ordered the appointment, and LVN B received the order and scheduled the appointment. However, the transportation request form did not specify that Resident 1 required a gurney for transport. As a result, the appointment was missed and had to be rescheduled. The Social Services Assistant (SSA C) later checked off the need for a gurney on the form after the missed appointment, indicating a lapse in communication and procedure. Interviews with the facility's staff, including the current Social Services Director, SSA C, LVN B, the Director of Nursing (DON), and the interim Administrator, revealed a lack of clarity and responsibility regarding who should ensure the correct transportation arrangements. The facility's policies indicated that the Social Services department was responsible for arranging transportation, but there was an expectation of collaboration with the Nursing Services staff to determine the necessary equipment for transport. This miscommunication and failure to follow proper procedures led to the deficiency in providing timely and appropriate transportation for Resident 1's medical appointment.
Failure to Document and Investigate Bruising on Resident's Eye
Penalty
Summary
The facility failed to document and perform a root cause analysis on how a resident sustained bruising on her eye. The resident, who was admitted with diagnoses of chronic pain, a fracture of the left humerus, and repeated falls, had a BIMS score indicating intact cognition and required significant assistance with activities of daily living. Despite the bruising being a change in condition, there was no documentation or investigation into the cause of the injury, nor was there any notification to the physician about the bruising. Multiple staff members, including unlicensed staff, licensed staff, the ADON, and the Infection Preventionist, confirmed that the bruising should have been documented, investigated, and reported to the physician, but this was not done. The ADON and other staff members acknowledged that the bruising was not present upon admission and that it should have been care planned and monitored as a safety issue. The facility's Skin Integrity Management Policy and Procedure was referenced, but it did not specifically address bruising, and no policy for changes in condition was provided. The lack of documentation and notification could lead to missed neurological symptoms and delayed treatment, posing a safety risk to the resident.
Failure to Anticipate Resident Needs and Ensure Safety
Penalty
Summary
The facility failed to ensure that Resident 1's needs were anticipated and that frequently needed items, such as water, were within reach. This failure resulted in Resident 1 falling on 1/31/24, causing a small cut on her left index finger. Resident 1 had a history of chronic pain, a fracture of the left humerus, and repeated falls, and required moderate to maximal assistance with activities of daily living. Her care plan included measures to prevent falls, such as providing verbal cues and reminding her to use the call light when attempting to ambulate and transfer. However, these measures were not adequately followed, leading to the fall incident when Resident 1 attempted to reach for water that was not placed within her reach on her good side, resulting in her losing balance and falling to the floor on her left side. Interviews with staff confirmed that the facility's fall prevention policies, including monitoring residents every two hours and placing frequently used items on the resident's uninjured side, were not consistently followed. The Assistant Director of Nursing (ADON) and the Infection Preventionist both acknowledged that the fall could have been prevented if the care plan had been properly implemented. Additionally, there was no record of a medication regimen review for falls being completed by the pharmacist, nor was there documentation indicating that Resident 1 was being monitored every two hours or that her water was within reach at the time of the fall.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
