St Andrews
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2300 W. Washington Blvd., Los Angeles, California 90018
- CMS Provider Number
- 555218
- Inspections on file
- 32
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Andrews during CMS and state inspections, most recent first.
A resident who required a pureed, honey-thick diet and one-on-one feeding was assisted with eating by a Receptionist who had not received training in feeding residents. The staff member reported that she was expected by the DON and other nursing staff to help with feeding and behavior monitoring, despite lacking the required training. Facility policy required all staff assisting with meals to be trained and competent in safe feeding practices.
A Restorative Nurse Assistant assisted two residents with their meals without performing required hand hygiene before and after contact, contrary to facility policy. Both residents required varying levels of assistance with eating due to medical conditions such as dysphagia, impaired mobility, and lack of coordination. The staff member acknowledged the lapse during the interview.
Staff did not inform a resident's responsible party about an alleged abuse incident or a dental visit, despite the resident lacking decision-making capacity and requiring full assistance with daily activities. The responsible party learned of the incident from the Ombudsman and was not notified in advance of the dental care, contrary to facility policy requiring prompt communication with representatives.
Surveyors identified multiple deficiencies in food storage and sanitation, including unlabeled and expired food items in refrigerators and freezers, lack of a designated area for dented cans, and unclean kitchen equipment such as a mixer, food processor, and juice dispenser nozzle. These findings were inconsistent with the facility's own policies regarding food labeling, rotation, and equipment cleaning.
The facility did not update its Facility Assessment Tool to reflect the current average daily census, resulting in three residents not being accounted for in the assessment. The Administrator acknowledged the discrepancy and confirmed that the tool was not revised as required by facility policy and CMS guidance, potentially impacting the planning for necessary care resources.
A resident with significant physical impairments and a need for substantial assistance with dressing was observed repeatedly exposed due to ill-fitting pants, while staff did not intervene. Staff interviews confirmed awareness of the issue and available resources for clothing, but the resident continued to struggle with his clothing and exposure, contrary to facility policy on dignity.
A resident with multiple medical conditions and intact cognition was denied the ability to choose snacks due to a physician order restricting snack options and instructing staff to falsely claim snacks had run out. The resident expressed frustration at not being able to receive preferred snacks, while staff confirmed that snacks were available and acknowledged the order was inappropriate, contrary to facility policy supporting resident rights and dignity.
A resident with severe cognitive impairment and multiple contractures repeatedly refused ordered ROM therapy for several days, but the physician and family were not notified as required by facility policy. Staff interviews and record review confirmed the lack of notification and documentation, resulting in delayed continuity of care.
A resident with severe cognitive impairment and multiple diagnoses was approved for Medi-Cal, but the responsible party was not promptly notified of the insurance approval or share of cost. Despite attempts to contact the responsible party and their frequent presence at the facility, there was no confirmation or documentation that the required notification was provided, contrary to facility policy.
A resident with multiple medical conditions had their MDS 5-day scheduled assessment submitted to CMS significantly later than the required 14-day timeframe after the Assessment Reference Date. Review of records and staff interview confirmed the late submission, which was also documented in the facility's validation report. Facility policy required timely completion and transmission of MDS assessments in accordance with federal and state regulations.
Two residents received inaccurate MDS assessments: one had a medication incorrectly coded as a hypnotic instead of an antidepressant, and another was incorrectly marked as having significant weight loss despite not meeting the criteria. Both residents had cognitive impairments and required maximal assistance, and these errors were confirmed by the MDS nurse during review.
A resident with anxiety disorder and major depressive disorder, who was receiving psychotropic medications, was not reassessed or referred for a PASARR Level II evaluation after admission. The facility relied on an outdated screening from another facility that did not reflect the resident's current mental health status or medication use, contrary to policy and regulatory requirements.
A resident with multiple diagnoses, including muscle weakness and bipolar disorder, had orders for weekly orthostatic blood pressure monitoring. Over several weeks, the blood pressure readings documented for both lying and sitting positions were identical each time, with no variation. The DSD identified this as suspicious and inconsistent with expected results, raising concerns about the accuracy of the measurements and documentation, which did not follow facility policy.
A resident with severe cognitive impairment and an unstageable pressure ulcer was found to have a low air loss mattress set for 320 lbs despite weighing only 76 lbs. An LVN confirmed the setting was incorrect and that mattress settings should be based on weight, as per manufacturer instructions. This failure to adjust the mattress appropriately constituted a deficiency in pressure ulcer care.
A resident with a left forearm contracture and severe joint mobility limitation did not receive a hand roll as needed, despite staff awareness and facility policy requiring restorative care. The resident was observed without adaptive equipment, and staff interviews confirmed the oversight in implementing this intervention.
A resident with severe cognitive impairment and multiple medical conditions did not have their driver's license renewed in a timely manner due to delays and lack of follow-up by the Social Services Director, who was responsible for the process. This resulted in a delay in the delivery of care and services, as the required renewal was not completed promptly.
A nurse opened a Duloxetine DR capsule labeled 'Do Not Crush', mixed its contents with applesauce, and administered it to a resident with severe cognitive impairment and swallowing difficulties. The medication guide specified the capsule should be swallowed whole, but the nurse stated medications were routinely crushed for this resident.
A resident with a history of seizures, chronic kidney disease, and diabetes had physician orders for monthly CBC, CMP, and Keppra blood level tests, but these labs were not drawn for several months. An LVN confirmed the missed tests and acknowledged their importance for monitoring the resident's condition and medication levels, in violation of facility policy.
The facility did not provide the required minimum of 80 square feet per resident in 11 multi-resident rooms, as confirmed by observation and staff interview. Although residents could move freely and use necessary equipment, the rooms measured less than the required space for three occupants.
A resident with schizophrenia, bipolar disorder, and major depressive disorder did not have a care plan for physical aggression, despite being cognitively intact and requiring maximal assistance for daily activities. Interviews with an LVN and the DON confirmed the absence of a care plan, which should have included interventions to manage the resident's behavior. The facility's policy emphasized the need for comprehensive care plans, which was not followed in this instance.
A facility failed to follow a physician's order to monitor a resident for negative psychological impact after an altercation. The order was not documented in the Medication Administration Record, leading to a lack of monitoring. Interviews with staff revealed the oversight, and the facility's policy emphasized the need for accurate and timely execution of orders.
A facility failed to create a resident-centered care plan for a Foley catheter, risking poor care quality and complications. Despite the resident's need for substantial assistance and catheter care, no plan was developed, contrary to facility policy. This was confirmed by interviews with an RN and the DON.
A resident with hemiplegia and osteoporosis experienced an unwitnessed fall, leading to a care plan that included a landing pad and alarm. However, during an observation, these interventions were not in place, as confirmed by the LVN and DON. This failure to implement the care plan increased the risk of falls and injury, violating facility policies on safety and fall risk management.
A resident with hemiplegia and osteoporosis experienced a fall, leading to physician orders for a landing pad and alarm. However, these interventions were not in place during an observation, as confirmed by an LVN and the DON, increasing the risk of further falls and injuries.
An LVN failed to follow medication administration procedures by leaving medications at a resident's bedside and documenting them as administered without ensuring they were taken. The resident had conditions requiring specific vital sign ranges for safe medication administration. The facility's policy prohibits leaving medications at the bedside and mandates observing the resident taking them.
The facility failed to notify a resident's representative after the resident, who has COPD, dementia, and muscle weakness, was found on the floor. Despite the resident's son requesting to be informed of falls, the LVN did not notify the son or the doctor due to the absence of injuries. The DON confirmed that the son should have been informed regardless of injury presence.
The facility failed to provide adequate supervision for a resident who was left alone on the floor after a fall. The resident, dependent on staff for most activities, was found on the floor by their roommate. An LVN assessed the resident but left them alone to get assistance, during which time the roommate put the resident back to bed. Interviews confirmed that staff should not leave a resident alone after a fall, as per facility policy.
The facility failed to maintain accurate documentation for a resident with COPD, dementia, and muscle weakness. The resident was found on the floor, and the LVN did not notify the family or doctor, despite documentation stating otherwise. The DON confirmed the inaccuracy, and the family was upset upon later notification.
The facility failed to replace a non-antibiotic Emergency Kit (E-Kit) within 72 hours as required by policy. An LVN identified an opened E-Kit with a red seal tag that had not been replaced since it was opened. The DON acknowledged the lack of daily checks and documentation for the E-Kits, which are crucial for providing medications during emergencies.
The facility failed to ensure food items were labeled properly and expired food was not stored in the kitchen, potentially leading to foodborne illnesses. Observations revealed expired potato fries and unlabeled celery and tortillas, which were discarded. The dietary supervisor acknowledged the risks of not labeling food items.
The facility failed to document and maintain a temperature log for two commercial front-loading clothes dryers, as observed during a survey. The laundry aide and Maintenance Supervisor confirmed the absence of temperature monitoring, which is essential for infection control. The Administrator and Infection Preventionist Nurse acknowledged the deficiency, despite the facility's Infection Prevention and Control Manual Program and the Maintenance Supervisor's job description indicating the importance of such logs.
The facility failed to ensure a peripheral catheter (IV) dressing was dated for a resident, posing a risk of infection. The resident had an IV on the left forearm without a date and time of placement, contrary to the care plan and facility protocol. The DON confirmed the protocol required dating the IV dressing, and the facility's policy mandated IV site rotation every 72 hours.
A resident with COPD and heart failure was administered oxygen without a physician's order, contrary to the facility's policy. Both the RN and DON confirmed that oxygen should not be given without an order, as it poses risks of inappropriate administration and respiratory distress.
The facility failed to perform competency assessment skills checks upon hire and annually for two out of five randomly selected staff members. The Director of Staff Development confirmed that these checks are essential to validate the skills needed to ensure resident health and safety, as emphasized by the Director of Nursing.
The facility failed to re-evaluate and renew a PRN order for lorazepam for a resident with severe cognitive impairment and multiple diagnoses, leading to the potential use of unnecessary medication. The order, written on 4/8/2024, was not reviewed or renewed after 14 days as required by regulation.
The facility failed to properly label and remove expired medications for two residents, leading to potential risks of ineffective treatment and adverse reactions. An LPN found opened ipratropium with albuterol inhalation solutions in the medication cart for two residents, both exceeding the recommended two-week usage period. The facility's policy on medication storage and labeling was not followed.
The facility failed to document insulin injection location sites for a resident, potentially leading to skin and tissue damage. Despite policies requiring documentation, the injection sites for insulin glargine were not recorded in the MAR, as confirmed by both an LVN and the DON.
The facility failed to meet the required 80 square feet per resident in multiple resident bedrooms for 11 of 23 rooms. Each affected room measured 224.40 square feet, insufficient for the number of residents housed. The Administrator acknowledged that 22 residents were affected but stated that the room size did not negatively impact the residents and that there was sufficient room for nursing services.
Untrained Staff Provided Feeding Assistance to Dependent Resident
Penalty
Summary
A facility failed to ensure that only trained staff provided feeding assistance to a resident who required a pureed diet and one-on-one feeding. During an observation, a Receptionist, who had not received training on feeding residents, was seen feeding a resident with a pureed, honey-thick diet in the front lobby. The resident's records indicated dependence on staff for eating, oral hygiene, and personal hygiene, and physician orders specified the need for one-on-one feeding with a teaspoon only, as well as monitoring for swallowing difficulties and behaviors. The Receptionist confirmed in an interview that she had not been trained to feed residents and that the DON and other nursing staff expected her to assist with feeding and behavior monitoring. Facility policy required that all employees assisting with meals be trained and demonstrate competency in safe feeding practices. The failure to follow these policies resulted in an untrained staff member feeding a resident with significant dietary and behavioral needs.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
During a lunch observation in the activity room, a Restorative Nurse Assistant (RNA) was seen assisting two residents with their meals without performing hand hygiene before and after providing assistance. The RNA sat between the two residents, helped one with using a fork, and fed the other with a spoon, but failed to wash hands or use an alcohol-based sanitizer as required by facility policy. The RNA acknowledged during the interview that assisting two residents simultaneously and neglecting hand hygiene could contribute to the spread of germs. Resident 3 had a history of cerebral atherosclerosis, dysphagia, and hypertension, and required substantial assistance with activities of daily living, including eating. Resident 4 had diagnoses of dysphagia following cerebral infarction, failure to thrive, and lack of coordination, and required supervision or touching assistance with eating. Both residents had care plans indicating the need for staff assistance during meals. The facility's hand hygiene policy required staff to perform hand hygiene before and after direct contact with residents and when assisting with meals, which was not followed in this instance.
Failure to Inform Responsible Party of Significant Events and Care Decisions
Penalty
Summary
Staff failed to ensure that a resident's responsible party was fully informed about significant events and care decisions. Specifically, the responsible party was not notified by facility staff about an alleged abuse incident involving the resident, learning of the event instead from the Ombudsman. The administrator later acknowledged that the responsible party should have been informed, but stated that the incident was not reported to the family because the abuse allegation was anonymous and unsubstantiated. This lack of communication left the responsible party feeling ignored and uninformed about the resident's care. Additionally, the responsible party was not notified in advance of a dental visit for the resident, despite having previously requested that the resident not be seen by the dentist due to concerns about unnecessary use of benefits. The dental office confirmed that the resident was seen for an initial visit and x-rays, and the administrator stated that social services was responsible for notifying the responsible party but failed to do so. The facility's policy requires prompt notification of changes in a resident's condition or care to the resident's representative, which was not followed in these instances. The resident in question had diagnoses of hyperlipidemia and hypertension, and was assessed as lacking capacity to make decisions, requiring full assistance with daily activities.
Deficient Food Storage, Labeling, and Sanitation Practices Identified in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and cleanliness of food and equipment. Opened food items such as parmesan cheese, roast beef, lemon juice, and tamales were found in various refrigerators and freezers without required labels or open dates. Some items, including parsley and jelly, were expired and had not been discarded. Additionally, certain food items were labeled with incorrect dates, making it unclear when they were opened or if they were still safe for consumption. During the inspection, it was also noted that the dry storage area lacked a designated and labeled area for dented cans, contrary to facility policy. The kitchen mixer and food processor were found to be unclean, with visible residue and debris, indicating they had not been properly washed after use. The juice dispenser nozzle was observed with an orange residue, and upon wiping, it was found to be unclean, despite staff initially stating it was a permanent stain. The facility did not have a policy specifying how often the juice nozzles should be cleaned. Review of the facility's policies and procedures confirmed requirements for labeling and dating foods, proper rotation and disposal of expired items, separation and labeling of dented cans, and cleaning of kitchen equipment after each use. The observed practices did not align with these policies, resulting in deficiencies related to food safety and sanitation standards.
Failure to Update Facility Assessment Tool with Accurate Census
Penalty
Summary
The facility failed to revise and provide an updated average daily census in its Facility Assessment Tool, which is used to evaluate the resident population and identify necessary resources for care and services. On review, the census for a specific date showed 54 residents, while the Facility Assessment Tool, last updated several months prior, listed an average daily census of 51 residents. During an interview and record review, the Administrator acknowledged that the assessment did not reflect the current census, with three residents unaccounted for, and confirmed responsibility for updating the tool. The Administrator also stated that the Facility Assessment Tool should be updated annually and as needed when there are changes in the resident population or facility operations. The facility's policy indicated that the Facility Assessment must be reviewed and updated annually or sooner if there are significant changes in census or resident acuity. CMS guidance further requires that the assessment include an evaluation of resident diseases, conditions, and acuity, and be updated whenever there is a substantial change. The failure to maintain an accurate and current Facility Assessment Tool had the potential to place residents at risk for delays in care and treatment services.
Failure to Maintain Resident Dignity Due to Inadequate Assistance with Clothing
Penalty
Summary
A resident with multiple medical conditions, including Parkinson's disease, peripheral autonomic neuropathy, restless leg syndrome, contractures, and polyosteoarthritis, was observed to have ill-fitting clothing that exposed his buttocks. The resident required substantial to maximal assistance with dressing and other activities of daily living, as documented in his Minimum Data Set assessment. Despite this, staff were observed walking by while the resident repeatedly attempted to adjust his loose pants to cover himself, without offering assistance. Interviews with staff confirmed awareness of the resident's need for help with dressing and the inappropriateness of his exposure. The social services designee stated that extra clothing was available for residents in need and that it was not appropriate for a resident to have exposed buttocks. The resident himself reported ongoing difficulty keeping his pants up. Facility policy requires staff to treat residents with dignity and respect and to identify and address individual needs through assessment, but this was not followed in this instance.
Failure to Honor Resident Snack Preferences and Choice
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding snack preferences. A resident with diagnoses including obesity, chronic pulmonary edema, type 2 diabetes, and hemiplegia, who was cognitively intact and dependent on staff for activities of daily living, was subject to a physician order that restricted snacks to only healthy options and instructed staff to tell the resident that snacks had run out if he requested more. The resident reported feeling frustrated when told that snacks were unavailable, despite his desire for more and enjoyment of snacks such as ice cream. Staff interviews and record reviews revealed that the facility had not actually run out of snacks, and a Licensed Vocational Nurse acknowledged that the physician order was inappropriate and that residents should be provided snacks when requested. Facility policies reviewed indicated that residents have the right to exercise choice and dignity, including decisions about food and daily activities. The practice of misleading the resident about snack availability directly limited his ability to make choices about his food preferences.
Failure to Notify Physician of Resident's Repeated Refusal of ROM Therapy
Penalty
Summary
The facility failed to notify the physician and resident representative when a resident with severe cognitive impairment and multiple physical disabilities refused prescribed range of motion (ROM) therapy over several consecutive days. The resident, who was dependent on staff for all activities of daily living and had a history of stroke, hemiplegia, and contractures, was documented as refusing ROM exercises for eight consecutive days. Despite facility policy requiring physician notification after two or more consecutive refusals, there was no documentation of such notification in the clinical record. Interviews with facility staff, including an LVN and the DON, confirmed that neither the physician nor the family had been informed of the resident's ongoing refusal of therapy, as required by both the care plan and facility policy. The lack of timely notification resulted in delayed continuity of care for the resident, who was observed to be nonverbal and immobile in bed during the survey period.
Failure to Notify Responsible Party of Medicaid Approval and Share of Cost
Penalty
Summary
The facility failed to notify the responsible party or Power of Attorney of a resident's Medi-Cal insurance approval in a timely manner. The resident in question was admitted with multiple diagnoses, including myalgia, unspecified dementia, unspecified psychosis, and toxic encephalopathy, and was assessed as having severely impaired cognitive skills and requiring maximal assistance with activities of daily living. According to the Social Service Director (SSD), both she and the Business Office Manager (BOM) were responsible for notifying residents or their responsible parties of Medi-Cal approval. Although the resident's Medi-Cal insurance was approved in August, the SSD did not notify the responsible party until several months later, in March, due to an outstanding share of cost balance. The BOM stated that she attempted to call the responsible party in October to inform them of the Medi-Cal approval and share of cost, but the call was not answered. Despite frequent visits and calls from the responsible party, there was no documentation or confirmation that the responsible party was notified of the insurance approval or the share of cost. The facility's policy and procedures require the Social Services Designee to provide information to residents and families regarding Medicare/Medicaid and other financial assistance programs, but this was not followed in this instance.
Failure to Timely Transmit MDS Assessment to CMS
Penalty
Summary
The facility failed to transmit a resident's Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day timeframe after completion. Specifically, a resident who was admitted with diagnoses including urinary tract infection, diabetes mellitus, and cerebrovascular accident had an MDS 5-day scheduled assessment with an Assessment Reference Date (ARD) of 11/29/2024. The assessment was not submitted to CMS until 2/28/2025, which was well beyond the regulatory submission window. Record review and staff interview confirmed that the MDS Nurse was aware of the federal requirement to submit MDS assessments in a timely manner for accurate billing and compliance. Facility policy also required all MDS assessments to be completed and transmitted according to federal and state timeframes. The late submission was verified through the CMS MDS 3.0 NH Validation Report, which showed the assessment was transmitted more than 14 days after the ARD.
Inaccurate MDS Assessments for Medication Classification and Weight Loss
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS quarterly assessment incorrectly coded Trazodone, a medication prescribed for insomnia, as a hypnotic under Section N0415, when it should have been classified as an antidepressant based on its drug class, not its use. The MDS nurse acknowledged the error, noting that the medication coding should reflect the drug classification, not the indication for which it was prescribed. This resulted in inaccurate data being transmitted to CMS. For another resident, the MDS assessment inaccurately indicated significant weight loss under Section K0300, coding 'Yes' for significant weight loss when the resident's documented weight changes did not meet the criteria of 5% loss in one month or 10% in six months. The MDS nurse confirmed the error, stating that the resident's weight loss was not significant according to the MDS definitions. Both residents had cognitive impairments and required maximal assistance with daily activities, and the inaccuracies in their assessments were identified through record review and staff interviews.
Failure to Reassess and Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening and refer a resident with diagnoses of anxiety disorder and major depressive disorder (MDD) for a Level II evaluation, as required. The resident was initially admitted and later readmitted to the facility, with medical records indicating diagnoses of MDD, anxiety disorder, and congestive heart failure. The resident was assessed as having the capacity to make decisions and was independent in cognitive skills for daily decision making. Orders were placed for psychotropic medications, including Buspirone for anxiety and Sertraline for depression. Despite these diagnoses and the use of psychotropic medications, the facility relied on a previous PASARR Level I screening from another facility, which did not identify serious mental illness or psychotropic medication use at that time. The Minimum Data Set Nurse acknowledged that a new PASARR Level I screening should have been completed and resubmitted due to the resident's current mental health diagnoses and medication regimen. Facility policy and the PASRR reference manual both require referral for Level II evaluation when there is a new or significant change in mental health status, which was not done in this case.
Failure to Accurately Obtain and Document Orthostatic Blood Pressure Readings
Penalty
Summary
The facility failed to properly obtain and document accurate orthostatic blood pressure readings for a resident who was admitted with diagnoses including bipolar disorder, muscle weakness, and lack of coordination. The resident was cognitively intact and had no issues with upper or lower extremity movement. Physician and pharmacist orders required weekly monitoring for orthostatic hypotension by taking blood pressure readings in two different positions, 3-5 minutes apart, and to notify the physician if there was a significant drop in blood pressure. However, review of the Medication Administration Records over several weeks showed that the blood pressure readings recorded for both lying and sitting positions were exactly the same each time, with no variation. During an interview and record review, the Director of Staff Development noted that it was suspicious and questionable for the readings to be identical, as some variation would always be expected. The DSD was unable to determine if the issue was due to improper technique, documentation errors, or a problem with the charting system. The facility's policy defined orthostatic hypotension and outlined the correct procedure for measurement, which was not followed in this case. As a result, the documentation did not provide accurate information to determine if the resident had orthostatic hypotension.
Incorrect Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with an unstageable pressure ulcer and deep tissue damage was found to have their low air loss mattress set incorrectly. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, weighed 76 lbs, but the mattress was set to support 320 lbs. This discrepancy was observed during a concurrent observation and interview with a Licensed Vocational Nurse (LVN), who confirmed the setting was inappropriate for the resident's weight. The manufacturer's instructions for the low air loss mattress specified that the pressure should be adjusted according to the resident's weight. The LVN acknowledged that the incorrect setting could result in skin breakdown and wounds. The failure to ensure the mattress was set correctly for the resident's weight constituted a lapse in providing appropriate pressure ulcer care and prevention.
Failure to Provide Hand Roll for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of left forearm contracture, cerebrovascular accident, and hypertension did not receive appropriate services to prevent further decline in joint range of motion (ROM). The resident's records indicated severe joint mobility limitation in the left hand and fingers, and assessments showed the need for maximal assistance with daily activities. Despite these findings, the resident was observed without any adaptive equipment, such as a hand roll, in place to prevent further contracture of the left hand. Interviews with facility staff revealed that the need for a hand roll had been reported by the Restorative Nursing Assistant to the Director of Rehab a month prior, but no action was taken to implement this intervention. The Director of Rehab acknowledged the oversight and confirmed that the resident would benefit from a hand roll to prevent further contractures. Facility policies reviewed indicated a commitment to providing restorative nursing care and preventing hand contractures, but these were not followed in this case.
Failure to Timely Renew Resident's Driver's License
Penalty
Summary
The facility failed to ensure timely renewal of a driver's license for a resident with severe cognitive impairment and multiple diagnoses, including myalgia, unspecified dementia, unspecified psychosis, and toxic encephalopathy. The resident required maximal assistance with activities of daily living, as documented in the Minimum Data Set. The Social Services Director (SSD) was responsible for handling identification and license renewals and was notified in June that the resident's driver's license needed renewal. However, the SSD did not initiate contact with the Department of Motor Vehicles (DMV) until November and only completed the renewal application in February of the following year. The SSD did not follow up with the DMV after submitting the application and assumed the resident's responsible party would handle any further steps. This lack of follow-up resulted in a delay in the renewal process. The facility's policy indicated that the SSD was responsible for assisting with appointments for residents and families as needed, but this responsibility was not fully carried out in this instance.
Improper Administration of Duloxetine DR Capsule
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered Duloxetine Delayed Release (DR) 30 mg capsules to a resident by opening the capsule, pouring the contents into a medication cup, mixing it with applesauce, and giving it to the resident. The medication packaging was clearly labeled with a 'Do Not Crush' sticker, and the manufacturer's medication guide specified that the capsule should not be opened, broken, or chewed, but swallowed whole. The nurse stated that the resident had difficulty swallowing medications, so nurses routinely crushed her medications for administration. The resident involved had a history of anxiety, ataxic gait, and muscle weakness, and was assessed as having severely impaired cognition and being unable to make medical decisions. The resident's medication orders included instructions to crush and mix all crushable medications with applesauce, but did not specify that Duloxetine DR capsules should be opened. The nurse acknowledged during the interview that opening a delayed release medication could cause stomach upset and affect absorption, indicating awareness of the error after the fact.
Failure to Perform Ordered Monthly Laboratory Tests
Penalty
Summary
The facility failed to follow physician orders for monthly laboratory testing for a resident with a history of seizures, chronic kidney disease, and diabetes mellitus type 2. The resident was admitted with these diagnoses and had an order for monthly Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Keppra blood level monitoring. Record review revealed that these laboratory tests were not performed for the months of July, August, September, and November, despite the standing orders. During an interview and record review, a Licensed Vocational Nurse confirmed the absence of the required lab results for the specified months and acknowledged the importance of these tests for monitoring the resident's medication levels and kidney function. The facility's policy indicated that physicians should be notified of diagnostic test results, but there was no evidence that the required labs were drawn or results communicated as ordered.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 11 out of 23 resident rooms. During a facility tour, it was observed that residents in the affected rooms were able to move in and out, and there was space for beds, side tables, and care equipment. However, the Maintenance Supervisor confirmed that these rooms did not meet the required square footage per resident. A review of the facility's waiver request letter indicated that there were no reported problems with resident safety or physical accommodation of needs, including accessibility for handicapped equipment, in these rooms. Specific measurements showed that each of the identified rooms, all housing three residents, provided less than the minimum required 240 square feet, with room sizes ranging from 216 to 231.24 square feet.
Failure to Develop Care Plan for Resident's Physical Aggression
Penalty
Summary
The facility failed to ensure that a care plan was developed and implemented for a resident who exhibited physical aggression. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder, was cognitively intact and required maximal assistance for activities of daily living. Despite these needs and the potential for physical aggression, there was no care plan in place to address this behavior. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of a care plan for the resident's physical aggression. The LVN acknowledged the importance of having a care plan to set goals and interventions for managing the resident's behavior. The DON also stated that a care plan should have been developed to focus on the physical altercation and include interventions such as monitoring the resident's whereabouts. The facility's policy and procedure on care plans emphasized the need for comprehensive, person-centered plans with measurable objectives to meet residents' needs, which was not adhered to in this case.
Failure to Follow Physician's Order for Resident Monitoring
Penalty
Summary
The facility failed to ensure that a physician's order was followed for a resident, which placed the resident at risk for continuing aggressive behavior after an altercation. The resident, who had diagnoses including moderate intellectual disabilities, osteomyelitis, and functional quadriplegia, was to be monitored for negative psychological impact every shift as per the physician's order dated 9/10/2024. However, this order was not transcribed to the Medication Administration Record, and there was no documentation of the monitoring being conducted. Interviews with the Licensed Vocational Nurse and the Director of Nursing revealed that the physician's order was overlooked and not followed, as it was not documented in the Medication Administration Record. The facility's policy and procedure on physician orders emphasized the importance of executing orders accurately and timely, with documentation in the patient's medical record. The lack of documentation meant that the physician would not be aware of the effectiveness of the orders, potentially affecting the resident's behavior and the safety of other residents.
Failure to Develop Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for the use of a Foley catheter for a resident, which had the potential to result in poor quality care and increased risk of complications such as urinary infections. The resident, who was admitted with diagnoses including end-stage renal disease and muscle weakness, required substantial assistance with activities of daily living and was dependent on others for toileting. Despite these needs, the facility did not create a care plan to address the resident's catheter care, as confirmed by a registered nurse during an interview. The facility's policy and procedure for catheter care, which was reviewed with the Director of Nursing, indicated that a care plan should have been developed to address the underlying problem and aim for catheter removal when possible. However, the facility did not follow this policy, and no individualized care plan was created for the resident's Foley catheter. This oversight was acknowledged by both the registered nurse and the Director of Nursing, highlighting a lapse in adhering to established protocols for catheter care.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement the fall prevention care plan for a resident who was admitted with conditions including hemiplegia, hemiparesis, lack of coordination, and osteoporosis. The resident was dependent on staff for activities of daily living and mobility. Following an unwitnessed fall, the resident's physician ordered a landing pad and an alarm to prevent further falls. However, during an observation, it was noted that the resident did not have a landing pad or a bed alarm in place as required by the care plan. Interviews with the LVN and the DON confirmed that the care plan interventions were not implemented, which increased the risk of falls and potential injury for the resident. The facility's policies on safety and fall risk management emphasized the need for individualized, resident-centered approaches, which were not followed in this case. The absence of the required safety measures was a direct violation of the care plan and facility policies, leading to the deficiency noted in the report.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident who was at risk for falls. The resident, who was admitted with conditions including hemiplegia, hemiparesis, lack of coordination, and osteoporosis, experienced an unwitnessed fall. Following this incident, the physician ordered a landing pad and an alarm to be placed at the resident's bedside to prevent further falls and potential injuries. However, during an observation, it was noted that these interventions were not in place, as the resident did not have a landing pad or a visible bed alarm. Interviews with the LVN and the DON confirmed that the care plan and physician orders required these safety measures, but they were not implemented. The LVN acknowledged the absence of the landing pad and alarm, which increased the risk of unwitnessed falls and injuries. The DON also confirmed that the lack of these interventions placed the resident at risk for injury and falls, as the alarm was intended to alert staff if the resident attempted to get up unassisted. The facility's policy on managing falls emphasized the need for staff to implement resident-centered fall prevention plans, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
Licensed Vocational Nurse (LVN) 1 failed to administer medications according to the facility's policy and procedure for a resident. The resident, who was admitted with conditions including hemiplegia, aphasia, paroxysmal atrial fibrillation, and high blood pressure, had medications left at his bedside by LVN 1 after refusing to take them. LVN 1 documented the medications as administered on the electronic medication administration record (EMAR) without ensuring the resident had actually taken them. This included medications for heart conditions that required the resident's blood pressure and heart rate to be within a certain range for safe administration. The facility's policy and procedure for medication administration, as reviewed with the Director of Nursing (DON), clearly stated that medications should not be left at the bedside and must be observed as taken by the resident before being documented as administered. The DON confirmed that leaving medications at the bedside posed a risk for other residents to accidentally take them and that medications requiring specific vital sign ranges should be administered at the time the vitals are taken. The policy also required that refusals of medication be documented promptly, which was not adhered to in this instance.
Failure to Notify Resident's Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident's representative after the resident was found on the floor. Resident 1, who has diagnoses including COPD, dementia, and muscle weakness, was found sitting on the floor on 4/29/2024. Despite the resident's son having requested to be informed of falls and other significant events, the Licensed Vocational Nurse (LVN 1) did not notify the son or the doctor because there were no signs or symptoms of injury. The Director of Nursing (DON) confirmed that the son should have been informed regardless of the presence of injuries. The facility's policy and procedure (P&P) mandates prompt notification of the resident, the resident's physician, and the resident representative in case of changes in the resident's condition or status. The P&P also states that a fall without injury is still considered a fall and requires notification. The failure to notify the resident's representative about the fall incident resulted in the representative being unaware of the event, which is a deficiency in the facility's adherence to its own policies and procedures.
Failure to Provide Adequate Supervision After Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident (Resident 1) who was left alone on the floor after a fall. Resident 1, who had diagnoses including COPD, dementia, and muscle weakness, was dependent on staff for most activities of daily living and mobility. On the night of the incident, Resident 1 attempted to get up from bed and fell. The assigned CNA was advised to watch Resident 1 to prevent a fall, but Resident 1's roommate later found them sitting on the floor. LVN 1 assessed Resident 1 but left them alone on the floor to get CNA 1 for assistance. When LVN 1 and CNA 1 returned, Resident 1 had already been put back to bed by their roommate, which was against protocol. Interviews with LVN 1, LVN 2, and the DON confirmed that staff should not leave a resident alone after a fall. The facility's policy on safety and supervision emphasized that resident supervision is a core component of their safety approach. The failure to provide continuous supervision after the fall had the potential to cause further injury to Resident 1 and the roommate who assisted them back to bed.
Inaccurate Documentation of Resident Incident
Penalty
Summary
The facility failed to maintain accurate documentation for one of the sampled residents, resulting in inaccurate documentation for an incident involving the resident. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), dementia, and muscle weakness, was found sitting on the floor. The change of condition evaluation indicated that the charge nurse attempted to reach the resident's family but was unsuccessful. However, during an interview, the Licensed Vocational Nurse (LVN) admitted that he did not notify the resident's son or the doctor because the resident did not show any signs or symptoms of injury. The Director of Nursing (DON) confirmed that the documentation was inaccurate as the LVN did not call the resident's family, contrary to what was recorded. The DON stated that staff should not document actions they did not perform. When the LVN eventually contacted the resident's family later that day, the family was already aware of the incident and was upset for not being notified earlier. The facility's policy and procedure guidelines emphasize that every entry should be recorded promptly and be complete, concise, descriptive, and accurate.
Failure to Replace Non-Antibiotic Emergency Kit Within 72 Hours
Penalty
Summary
The facility failed to follow its policy and procedure to replace the non-antibiotic Emergency Kit (E-Kit) within 72 hours. During an observation and interview, a Licensed Vocational Nurse (LVN) identified a non-antibiotic medication E-Kit with a red seal tag, indicating it had been opened. The E-Kit had a fill date of 2/13/2024 and was opened on 4/16/2024, but had not been replaced within the required 72-hour timeframe. The LVN acknowledged the importance of the E-Kit for providing medication during emergencies and confirmed that it had not been replaced since it was delivered and filled by the pharmacy. The Director of Nursing (DON) stated that it was the responsibility of the licensed nursing staff to check and document the status of the medication E-Kits daily. However, there was no documentation or monitoring log to confirm that these checks were being performed. The facility's policy indicated that the E-Kit should be resealed with a red seal and the pharmacist notified when drugs are used or the yellow seal is broken, with drugs to be replaced within 72 hours. The DON acknowledged the lack of documentation and monitoring, which could potentially impact the availability of medications during emergencies.
Failure to Properly Label and Discard Expired Food
Penalty
Summary
The facility failed to ensure food items were labeled properly and expired food was not stored in the kitchen, which could potentially result in residents ingesting expired food and suffering from foodborne illnesses. During an observation and interview with a dietary aide, it was found that a plastic bag of seasoned potato fries in Freezer #2 had an open date that exceeded the three-month limit, leading to its disposal. Additionally, in Refrigerator #2, three opened bags of celery and one opened bag of flour tortillas were found without any received-by, open, or used-by dates, which were subsequently discarded by the dietary aide. The dietary supervisor confirmed that not labeling food items could cause confusion about their freshness and increase the risk of foodborne illnesses. The facility's policies and procedures were reviewed, revealing that leftover foods should be kept in the freezer for one month and that all food deliveries should be labeled with the delivery date or use-by date. The failure to adhere to these guidelines was evident in the observations made during the survey.
Failure to Maintain Temperature Log for Clothes Dryers
Penalty
Summary
The facility failed to document and maintain a temperature log for two commercial front-loading clothes dryers, which was observed during a survey. During an observation in the laundry area, it was noted that no temperature log was present for the clothes dryers. The temperature gauges on both dryers indicated 180 degrees Fahrenheit. The laundry aide confirmed that the facility did not monitor or log the temperature of the clothes dryers. The Maintenance Supervisor also confirmed that the temperature should be monitored twice a day and acknowledged the absence of a temperature log, emphasizing its importance for infection control. The Administrator and the Infection Preventionist Nurse both acknowledged the lack of a temperature log and its significance in the infection prevention and control program, although the facility had no existing policy for dryer maintenance logs. The facility's Infection Prevention and Control Manual Program indicated the importance of maintaining a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections. The Job Description of the Maintenance Supervisor also indicated the responsibility to keep maintenance logs up to date. Despite these guidelines, the facility did not have a temperature log for the clothes dryers, which is essential for ensuring the appropriate heat to kill germs and prevent potential infection transmission to residents.
Failure to Date IV Dressing
Penalty
Summary
The facility failed to ensure a peripheral catheter (IV) dressing was dated for a resident, which had the potential to lead to an infection and/or hospitalization. Resident 152, who had diagnoses including urinary tract infection, chronic obstructive pulmonary disease, and heart failure, was observed with an IV on the left forearm without a date and time of placement on the dressing. The resident's care plan indicated the need for IV therapy with site rotation every 72 hours, extendable to 5 days if free of complications. However, during an observation, the IV dressing lacked the required date and time, and the RN confirmed this was an infection control issue. The Director of Nursing (DON) stated that the protocol for IV placement required the date, time, and initials of the person who inserted the IV on the dressing. The DON also mentioned that Resident 152 was readmitted with the IV from the hospital, and the date of insertion was unknown. The facility's policy indicated that peripheral IVs should be removed and started in another site every 72 hours. The lack of proper documentation on the IV dressing posed a risk of infection at the IV site and in the bloodstream.
Oxygen Administration Without Physician's Order
Penalty
Summary
The facility failed to ensure respiratory care was consistent with professional standards of practice for Resident 152, who was administered oxygen without a physician's order. Resident 152, who had diagnoses including COPD and heart failure, was observed to be on oxygen via nasal cannula on two occasions in April 2024. However, a review of the resident's records revealed no physician's order for oxygen administration since the resident's readmission. This was confirmed by RN 1, who acknowledged that oxygen should not be given without a physician's order, as it poses a risk of inappropriate administration and potential acute respiratory failure, especially in residents with COPD. The Director of Nursing (DON) also confirmed that oxygen should not be administered without a physician's order, as staff would not know the correct amount to administer, potentially leading to respiratory distress. The facility's policy on oxygen administration requires checking the physician's order for the liter flow and method of administration, which was not followed in this case. This deficiency had the potential to result in unsafe use of oxygen equipment and other serious health risks for Resident 152.
Failure to Perform Competency Assessment Skills Checks
Penalty
Summary
The facility failed to ensure that competency assessment skills checks were performed upon hire and annually for two out of five randomly selected staff members. During an interview and record review, it was found that one Licensed Vocational Nurse (LVN) did not have a yearly competency assessment skills check on file, and another LVN did not have a competency assessment skills check done upon hire. The Director of Staff Development (DSD) confirmed that competency assessment skills checks must be done upon hire, yearly, and when new equipment is introduced. The DSD acknowledged that the competency assessment skills checks for the two LVNs were not completed, which is essential to validate the skills needed to ensure resident health and safety. The Director of Nursing (DON) emphasized the importance of performing competency assessment skills checks to ensure that all licensed nursing staff can provide the standard of care and practice required by regulations and to prevent malpractice. The facility's undated Policy and Procedure (P&P) titled
Failure to Re-evaluate PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that the order for a psychotropic medication, lorazepam, as needed (PRN), was limited to 14 days per regulation for one resident. Resident 43, who was admitted with diagnoses including end-stage heart failure, acute kidney failure, and anxiety disorder, had a PRN order for lorazepam 0.5 mg every two hours for agitation and inability to relax. This order, written on 4/8/2024, was not re-evaluated or renewed after 14 days, as required by regulation. Interviews with LVN 3 and LVN 4 confirmed that the order was over 14 days old and should have been discontinued or renewed on 4/22/2024. Both LVNs acknowledged the potential for the medication to become unnecessary if not re-evaluated regularly. The Director of Nursing (DON) reviewed the facility's policy and procedure on antipsychotic medication use, which indicated that PRN orders for psychotropic medications must be re-evaluated and renewed every 14 days. The DON confirmed that the lorazepam order for Resident 43 was not renewed as required, acknowledging the potential for the medication to become unnecessary. The failure to re-evaluate and renew the PRN order for lorazepam could result in the use of unnecessary medication for Resident 43, who had severe cognitive impairment and required maximal assistance for activities of daily living.
Failure to Label and Remove Expired Medications
Penalty
Summary
The facility failed to properly label and remove expired medications for two residents, leading to potential risks of ineffective treatment and adverse reactions. For Resident 40, who has chronic respiratory failure with hypoxia and congestive heart failure, an opened ipratropium with albuterol inhalation solution was found in the medication cart without a label indicating the date it was opened. The Licensed Vocational Nurse (LVN) was unable to determine when the medication was opened, and the medication had a pharmacy fill date that exceeded the recommended two-week usage period after opening. The manufacturer's guidelines state that the medication should be discarded within two weeks of opening the foil pack, but this was not adhered to, posing a risk to Resident 40's treatment efficacy and safety. Similarly, for Resident 45, who has anxiety disorder and neuralgia, an opened ipratropium with albuterol inhalation solution was found in the medication cart with an opened date that exceeded the two-week usage period. The LVN confirmed that the medication should have been discarded after 14 days but was still present in the cart. This oversight could lead to ineffective treatment of Resident 45's respiratory symptoms. The facility's policy and procedure on medication storage and labeling were not followed, as all drugs are required to be labeled and stored according to the manufacturer's specifications and relevant regulations.
Failure to Document Insulin Injection Sites
Penalty
Summary
The facility failed to document insulin injection location sites for one resident, which could potentially result in skin and tissue damage if injection sites were not rotated. Resident 101, who has diagnoses including type 2 diabetes mellitus with hyperglycemia, thrombocytopenia, peripheral vascular disease, and bipolar disorder, was administered insulin glargine every 12 hours from January 1, 2024, to April 27, 2024. However, the location site where the insulin was administered was not recorded in the Medication Administration Record (MAR). This was confirmed during interviews and record reviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the failure to document the injection sites. The LVN stated that residents who required insulin and were fully alert and oriented were asked their preferred placement for injection sites and were informed to ensure injection sites were rotated. Despite this, the location sites of insulin glargine administration for Resident 101 were not recorded in the MAR. The DON also confirmed that insulin injection sites were to be rotated and documented in residents' charts to prevent complications such as lipohypertrophy. The facility's policies and procedures indicated that the injection site should be recorded in the resident's medical record, but this was not adhered to in the case of Resident 101.
Facility Fails to Meet Required Room Size for Multiple Resident Bedrooms
Penalty
Summary
The facility failed to meet the required 80 square feet per resident in multiple resident bedrooms for 11 of 23 resident rooms. The affected rooms included rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 14, and 16, each measuring 224.40 square feet, which is insufficient for the number of residents they housed. This deficiency was identified through a record review of a room waiver letter dated 4/27/2024, in which the Administrator had requested a waiver for the room sizes. During an interview on 4/28/2024, the Administrator acknowledged that 22 residents were affected by the inadequate room sizes but stated that the room size did not negatively impact the residents and that there was sufficient room for the provision of nursing services for these residents.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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