Stoney Point Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chatsworth, California.
- Location
- 21820 Craggy View St., Chatsworth, California 91311
- CMS Provider Number
- 555574
- Inspections on file
- 59
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Stoney Point Healthcare Center during CMS and state inspections, most recent first.
A resident with encephalopathy, depression, and dementia, who required moderate to maximal assistance with ADLs, expressed discomfort with their room, and the responsible party requested a room change through Social Services. Social Services confirmed that another room was available and notified the RN Supervisor, but the transfer was not completed because the RN Supervisor reported being too busy during shift change. The DON confirmed that a room was available and that such requests should be acted on promptly, and facility policies state that residents are to be treated with dignity and that room changes are to be made when requested by the resident. This resulted in a failure to timely honor the resident’s request for a room change.
A resident's right to privacy and confidentiality was violated when the Social Services Director gave that resident's medical records to another resident's responsible party who had requested records. The SSD printed records from the printer and handed them over without confirming they matched the correct resident and without following the facility's required Authorization for Release of Records process, which involves review and approval by the MRD, DON, and Administrator. Facility policies on release of records and resident rights specified that records may only be released with proper authorization and that residents are entitled to confidentiality of their personal and medical information.
A resident with respiratory failure and severe cognitive impairment experienced a significant drop in oxygen saturation while receiving oxygen via nasal cannula. Facility staff did not increase the oxygen flow rate or switch to a non-rebreather mask as required by physician orders and facility policy. Paramedics arriving on scene found the resident still on low-flow oxygen and had to initiate high-concentration oxygen therapy before transferring the resident to the hospital.
Three residents received psychotropic medications without proper justification or monitoring. One resident was given an antipsychotic without documentation of required symptoms or evidence that non-drug interventions were attempted. Another was administered an anti-anxiety medication without first trying non-pharmacological approaches as ordered. A third resident received an anti-anxiety medication for weeks without behavioral monitoring to justify its use. These actions did not comply with facility policy or physician orders.
A resident did not receive the necessary care to maintain or improve range of motion or mobility, and there was no documented medical reason for the decline.
The facility did not act on consultant pharmacist recommendations for three residents, including failing to complete an EKG for a resident on Quetiapine, not ensuring proper documentation and monitoring for a resident on Seroquel, and lacking physician documentation for continued Klonopin use. These actions were not in accordance with facility policies and placed residents at risk for adverse effects.
Leftover food brought in by families and visitors was found in a resident refrigerator without proper labeling or resident identification. The Administrator in Training confirmed that all such food should be labeled with an identifier and use-by date, as required by facility policy, but this was not done in the observed instance.
Therapy staff did not accurately document the timing and completion of Rehab Joint Mobility Screens for several residents, failing to indicate late entries or how assessments were performed after the scheduled date. Additionally, a resident's diagnosis of anxiety was omitted from the medical record despite ongoing treatment, resulting in incomplete and inaccurate clinical documentation.
Staff did not knock or ask permission before entering the rooms of two residents with severe cognitive impairment and total dependence for ADLs. The CNA acknowledged forgetting to knock, and the DON confirmed that facility policy requires staff to do so to respect resident privacy and dignity.
A resident with impaired cognition and a need for supervision was found in bed with the call light on the floor and out of reach. Staff confirmed the call light should have been accessible, and facility policy requires it to be within easy reach for residents in bed or in a chair.
Two residents with significant medical needs had executed Advance Directives (ADs) that were not present in their active medical charts, despite facility policy requiring ADs to be accessible for staff reference. Both the Medical Records Director and Social Service Director confirmed the absence of these documents, and the ADON acknowledged that this failure meant staff could not easily access or honor the residents' healthcare wishes.
A resident with multiple diagnoses, including dementia and obstructive uropathy, was admitted with an indwelling catheter, but the baseline care plan developed within 48 hours did not document the catheter or related care needs. Facility staff confirmed the omission, which was inconsistent with policy requiring all immediate care needs to be addressed in the baseline care plan.
Two residents prescribed psychotropic medications did not have person-centered care plans developed or implemented to address their medication use. One resident with dementia and anxiety was given olanzapine without a corresponding care plan, and another resident with major depressive disorder and ADHD was prescribed amphetamine-dextroamphetamine without a care plan. Facility staff and policies confirmed that care plans were required for these medications to ensure proper monitoring and management.
A resident with cognitive impairment and multiple diagnoses lost her upper dentures, and although a dental evaluation was performed and further treatment was declined by the resident, the dental care plan was not updated or revised to reflect these changes, contrary to facility policy requiring care plan review after significant changes.
The facility did not accurately complete or update fall risk assessments for two residents with cognitive and mobility impairments after they experienced falls. In one case, a resident's fall was not documented in the fall risk assessment, and in another, staff failed to conduct a required fall risk assessment after a witnessed fall. These actions were not in accordance with facility policy, which requires timely and accurate fall risk assessments following such incidents.
A resident with end stage renal disease who was dependent on hemodialysis did not have their post-dialysis weight recorded by the dialysis center, and facility nursing staff did not follow up to obtain this information, resulting in incomplete documentation of dialysis care.
A resident was prescribed amphetamine-dextroamphetamine without a documented ADHD diagnosis, and staff failed to develop a care plan or obtain orders to monitor for adverse effects or effectiveness of the medication. Nursing and administrative staff confirmed that required monitoring and care planning for psychotropic medications were not completed, contrary to facility policy.
A resident with a documented egg allergy did not have this allergy indicated on her meal tray ticket, and was not provided with a protein substitute at breakfast when eggs were omitted. Multiple staff confirmed the allergy should have been marked on the tray ticket, and facility policy required both documentation and appropriate food substitutions for allergies and intolerances.
Two residents had inaccurate MDS assessments: one was incorrectly documented as discharged to a hospital instead of another SNF, and another did not have an active anxiety diagnosis listed despite clinical records and medication use for anxiety. These errors resulted in discrepancies between the MDS and other clinical documentation, as confirmed by staff interviews and record reviews.
A resident with mobility impairments and multiple medical conditions was discharged without her rollator walker, and there was no documented follow-up or timely replacement of the missing mobility aid, despite facility policy requiring provision of necessary adaptive equipment.
A resident with severe cognitive impairment was transferred to a new facility without being provided comprehensive information about the new location, as required by the facility's discharge policy. The Social Services Director informed the resident and their responsible party about the transfer but failed to include details about the services, quality measures, or care providers at the new facility, leading to a deficiency.
A facility failed to obtain informed consent from a resident's responsible party for the administration of Olanzapine, an antipsychotic medication. The resident, with diagnoses of psychosis and epilepsy, received the medication for six days without consent. The oversight was confirmed through record reviews and staff interviews, revealing a breach in the facility's policy requiring informed consent for psychotropic medications.
The facility failed to develop person-centered care plans for seven residents, including those with diabetes, psychotropic medication needs, viral hepatitis C, and UTIs. This deficiency involved the absence of care plans for insulin use, psychotropic medications, and antibiotic treatments, which are crucial for outlining interventions and ensuring appropriate care. The oversight was confirmed by the ADON and DON, who acknowledged the importance of care plans in managing residents' specific medical needs.
A resident with severe cognitive impairment was left with unattended medications, violating facility policy requiring nurse supervision during administration. Another resident's bed was not kept in the lowest position as ordered for fall prevention, and a high-risk resident lacked prescribed landing mats, both increasing fall risk. These deficiencies highlight lapses in following physician orders and facility policies.
A facility failed to document attempts of non-pharmacological interventions before administering prn opioid medications to a resident with polyneuropathy and chronic pulmonary edema. Despite physician orders for hydrocodone-acetaminophen, there was no documentation of non-drug interventions being tried first. Interviews with staff confirmed the lack of documentation, highlighting the importance of non-pharmacological measures to prevent unnecessary opioid use and potential side effects.
A resident with multiple health conditions did not receive her medications on time due to a nurse leaving them unattended at the bedside. The nurse became distracted by another resident, resulting in the resident not being observed taking her medications. This incident was against the facility's protocol, which requires medications to be administered within a specific timeframe and the resident to be observed to ensure ingestion.
The facility failed to maintain proper infection control practices for three residents, leading to potential contamination of medical equipment. A resident's catheter tubing was found touching the floor, another's oxygen equipment was improperly labeled and stored, and a third resident's nasal cannula tubing was inside a trash bin. These practices were against the facility's infection control policies and posed a risk of infection.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with COPD and coordination issues had a call light placed out of reach, despite requiring assistance with daily activities. Another resident with epilepsy and asthma had a call light hanging behind the bed, making it inaccessible. Both cases were confirmed by CNAs, and the DON highlighted the importance of accessible call lights to prevent falls.
A resident with severe cognitive impairment and requiring gastrostomy care did not receive full privacy during medication administration. LVN 3 left the privacy curtain partially open, violating the facility's policy on dignity and privacy. The DON emphasized the importance of privacy to protect resident dignity.
The facility failed to discard two bags of hotdog buns that were 12 days past their best by date, as observed during a kitchen inspection. A kitchen supervisor confirmed the buns were unsafe for consumption, which could have exposed 24 residents to foodborne illnesses. The facility's policy requires compliance with safe food handling practices.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential delays in care. One resident's MDS incorrectly indicated no falls despite a documented fall, while another's inaccurately reflected the presence of an advance directive. These errors were identified during reviews with an LVN, who stressed the importance of accurate MDS coding for proper care planning. The DON also emphasized the need for accurate assessments to affect residents' care plans.
A resident with impaired cognition and schizophrenia physically assaulted another resident with similar cognitive impairments, resulting in a cut, redness, and swelling around the victim's left eye. The incident was witnessed by an LVN who intervened, but the facility's failure to prevent the altercation violated its abuse prevention policy. The DON and AIT confirmed the incident as physical abuse.
The facility staff failed to follow the smoking policy when one resident shared a cigarette with another, both of whom have moderately impaired cognition and require assistance with mobility. Despite the policy prohibiting such actions, the staff member present did not prevent the sharing, which was confirmed by interviews with multiple staff members.
Failure to Timely Honor Resident Request for Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity by not completing a requested room change in a timely manner. The resident was admitted with encephalopathy, depression, and dementia, and while a History and Physical documented capacity to understand and make decisions, a subsequent MDS showed severely impaired cognition and a need for moderate to maximal assistance with ADLs. The resident’s responsible party reported requesting a room change from Social Services on 1/8/2026 because the resident felt uncomfortable in the current room, and Social Services confirmed that a suitable room was available and agreed to the change. Social Services staff stated they informed the RN Supervisor of the room change request on the same day but were unsure why the transfer was not completed. The RN Supervisor acknowledged being informed of the request and stated the room change was not done because it was very busy during change of shift, and further acknowledged that the room change should have been completed as soon as possible. The DON confirmed that when a room change is requested, it is to be discussed with social services, the DON, and the admissions coordinator, and that a room was available for this resident at the time of the request and the change should have occurred as soon as possible. Review of facility policies on Resident Rights and Room Change/Roommate Assignment showed that residents are to be treated with kindness, respect, and dignity, and that room changes are to be made when the resident requests them, which did not occur in this case.
Unauthorized Disclosure of a Resident's Medical Records to Another Resident's Representative
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's personal and medical records when the Social Services Director (SSD) provided the wrong chart to another resident's responsible party. Resident 2, who had been admitted with a lumbar vertebral fracture, type 2 DM, COPD, and dementia, had documentation indicating severely impaired cognition and a lack of decision-making capacity. Resident 1, admitted with encephalopathy, depression, and dementia, also had severely impaired cognition but was documented in the H&P as having capacity to understand and make decisions. During a meeting, Responsible Party 1 (RP 1) requested medical records for Resident 1, and the SSD printed records from the printer and handed them to RP 1 without verifying that they belonged to the correct resident. RP 1 later informed the facility that the records received were for a different resident, identified as Resident 2. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) revealed that facility policy required any requester of medical records to complete an Authorization for Release of Records, which must be reviewed and approved by the MRD, DON, and Administrator before records are released. The MRD and DON both stated that the SSD should not have provided Resident 2's medical records to RP 1 and that the established authorization and review process was intended to prevent disclosure of records to the wrong recipient. Review of facility policies on release of records and resident rights confirmed that records are to be released only upon properly completed authorization and that residents have rights to privacy and confidentiality of their records.
Failure to Provide Appropriate Oxygen Therapy for Resident with Low Oxygen Saturation
Penalty
Summary
Facility staff failed to provide respiratory care services consistent with professional standards of practice for a resident with a history of respiratory failure, prostate cancer, and dementia. The resident, who had severely impaired cognition and required significant assistance with daily activities, was admitted with physician orders to receive oxygen at 2 to 5 liters per minute (LPM) via nasal cannula, with instructions to titrate oxygen if saturation fell below 90%. On the morning in question, the resident was documented to have an oxygen saturation level of 80% while receiving oxygen via nasal cannula. Despite the low oxygen saturation, there was no documented evidence that staff increased the oxygen flow rate or administered high concentration oxygen using a non-rebreather mask prior to the arrival of paramedics. Interviews with the DON and a registered nurse confirmed that the resident continued to receive oxygen at 5 LPM via nasal cannula and was not switched to a non-rebreather mask. The facility's own policy required staff to adjust oxygen delivery devices and flow rates as needed and to document all assessment data and interventions, but this was not done in this case. When paramedics arrived, they found the resident with an oxygen saturation of 83% on 4 LPM via nasal cannula, a heart rate of 122, and a respiratory rate of 41. Paramedics questioned facility staff about the lack of appropriate oxygen therapy, but no explanation was provided. The paramedics then administered oxygen at 15 LPM via non-rebreather mask and provided additional care before transferring the resident to the hospital.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use by not meeting required conditions for prescribing and monitoring these medications. For one resident with dementia and mood disturbance, Seroquel was prescribed for 'psychosis manifested by sudden anger outburst' without documentation that the symptoms were due to mania, psychosis, or delusions, or that the behaviors presented a danger to the resident or others. There was also no evidence that the symptoms were not due to a medical condition expected to resolve, or that non-pharmacological interventions had been attempted and found ineffective. The resident’s family member, who was the primary decision maker, refused a gradual dose reduction despite recommendations from the pharmacist and nurse practitioner, and staff interviews indicated the resident’s behaviors were limited to yelling or screaming, with no significant aggression or danger noted. Another resident with cognitive and coordination deficits was prescribed Ativan on an as-needed basis for anxiety manifested by agitation and verbal aggression. The physician’s order required that non-pharmacological interventions be attempted prior to medication administration. However, documentation showed that Ativan was administered without any record of such interventions being tried first, contrary to the order and facility policy. The DON confirmed that non-pharmacological approaches should have been attempted and documented before medicating the resident. A third resident with generalized anxiety disorder and bipolar disorder was prescribed Clonazepam for anxiety. Behavioral monitoring was not initiated at the start of medication administration, and for several weeks, there was no documentation of behavioral assessments prior to giving the medication. The RN and DON both acknowledged that behavioral monitoring should have started with the initiation of Clonazepam, and that the lack of documentation meant the medication was being administered without an indication. Facility policy required monitoring for effectiveness and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was due to a documented medical reason. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Act on Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist's monthly Medication Regimen Review (MRR) were acted upon for three residents. For one resident prescribed Quetiapine, the pharmacy recommended an EKG to monitor for potential cardiac effects, but the EKG was not completed as ordered. Both the registered nurse and the assistant director of nursing confirmed that the EKG was missed and not documented in the resident's record, despite the pharmacy's recommendation and the facility's policy requiring such follow-up. Another resident was prescribed Seroquel for psychosis manifested by sudden anger outbursts. The consultant pharmacist recommended ensuring proper documentation for the use of Seroquel, including evidence that the symptoms were due to mania or psychosis, that non-drug interventions had been attempted, and that the behaviors presented a danger or significant distress. The pharmacist also recommended monitoring for orthostatic hypotension and obtaining specific lab tests. The facility did not ensure that these recommendations were followed, and the required documentation and monitoring were not completed in a timely manner. The resident's family member refused a gradual dose reduction, but the facility did not escalate the issue to the medical director as outlined in their policy. A third resident was receiving Klonopin for behavioral control without a documented progress note from the physician explaining why this long-acting benzodiazepine was the best choice. The consultant pharmacist requested updated documentation, but the physician's progress note did not address the rationale for continued use. The director of nursing confirmed that the required documentation was missing, and the resident could be receiving the medication without an appropriate indication. These failures were contrary to the facility's policies and procedures regarding psychotropic medication use and documentation.
Improper Labeling and Storage of Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date before being stored in the resident refrigerator. During an observation with the Administrator in Training (AIT), two plastic bags containing undetermined leftover food were found in the residents' refrigerator at the nurse's station without any labeling or resident identification. The AIT confirmed that the refrigerator is used for storing residents' food and acknowledged that all leftover food should be labeled with an identifier and date. The facility's policy requires perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date, and specifies that nursing staff are responsible for discarding perishable foods on or before the use-by date. However, the observed practice did not comply with this policy.
Failure to Accurately Document Clinical Records and Resident Diagnoses
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four residents. Specifically, therapy staff did not accurately document the completion of Rehab Joint Mobility Screens (JMS) for three residents. For each of these residents, the JMS was dated for a specific quarter but was actually completed and signed several months later. The documentation did not indicate that these were late entries, nor did it specify how the range of motion (ROM) measurements were obtained after the fact. Both the co-Director of Rehabilitation and the Assistant Director of Nursing confirmed during interviews that the JMS should have been completed on time, and if late, should have been clearly documented as such with an explanation for the delay and the method of assessment. For one resident, the facility also failed to ensure that a diagnosis of anxiety was included in the resident's medical record, despite evidence in the history and physical, care plan, and psychiatric progress notes that the resident was being treated for anxiety with Ativan. The omission of this diagnosis from the resident's official diagnosis list meant that the medical record did not accurately reflect the resident's conditions or the rationale for prescribed medications. Multiple staff, including the Quality Assurance Nurse, MDS Nurse, and Director of Nursing, acknowledged during interviews that the anxiety diagnosis should have been included in the resident's record to ensure accurate documentation and appropriate care planning. The facility's policy and procedure on charting and documentation, last reviewed in January 2025, requires that all services provided to residents and any changes in their medical or mental condition be documented in the medical record. The failure to accurately document the timing and method of JMS assessments, as well as to include all relevant diagnoses, resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Knock and Request Permission Before Entering Resident Rooms
Penalty
Summary
Facility staff failed to honor residents' rights to dignity and privacy by not knocking or asking permission before entering the rooms of two residents. Both residents had severe cognitive impairments and were totally dependent on staff for activities of daily living. During an observation, a Certified Nurse Assistant (CNA) was seen entering the rooms of these residents without knocking or requesting permission, despite the residents being present in their beds at the time. Upon interview, the CNA acknowledged forgetting to knock and recognized the importance of doing so, as this is considered the residents' home. The Director of Nursing confirmed that facility policy requires staff to knock and request permission before entering any resident's room, emphasizing the need to respect residents' privacy and dignity. A review of the facility's policy further supported this expectation for staff behavior.
Call Light Not Accessible to Resident in Bed
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dysphagia and schizophrenia, and documented impaired cognition, was observed in bed without their call light within reach. The call light was found on the floor, making it inaccessible to the resident. The resident's Minimum Data Set indicated a need for supervision with activities of daily living, highlighting the importance of having the call light accessible for requesting assistance. During the observation, a Certified Nurse Assistant confirmed that the call light should be placed behind the pillow to ensure it is within reach. The Administrator in Training also acknowledged that the call light is the primary means for residents to request help and should always be accessible. Facility policy reviewed stated that the call light must be within easy reach when a resident is in bed or confined to a chair. The failure to ensure the call light was accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that copies of executed Advance Directives (ADs) were kept in the active medical charts and were easily retrievable for two residents. For one resident with diagnoses including dysphagia, type 2 diabetes, and anemia, the admission record and Minimum Data Set (MDS) confirmed the resident was able to communicate and required staff assistance for several activities of daily living. The Advance Directive Acknowledgement (ADA) form indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Medical Records Director, it was found that the AD was not present in the resident's chart, despite facility policy requiring it to be accessible in case of emergency. The Assistant Director of Nursing (ADON) confirmed that the AD should have been in the chart to guide staff regarding the resident's wishes. For a second resident with diagnoses including dysphagia, dementia, and anemia, the MDS showed severely impaired cognitive skills and a need for substantial staff assistance. The ADA form and a Physician Orders for Life-Sustaining Treatment (POLST) form both indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Social Service Director, it was determined that the AD was not present in the resident's chart. The Social Service Director and the ADON both stated that the AD should have been in the active chart to ensure staff could reference the resident's healthcare wishes. The facility's policy and procedure on Advance Directives, last reviewed in January, required that AD documents be placed in a prominent, accessible location in the medical record and that the resident's wishes be communicated to direct care staff and the physician. In both cases, the facility did not follow its own policy, resulting in the absence of the residents' ADs from their medical charts.
Failure to Include Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the resident was admitted and readmitted with multiple diagnoses, including dysphagia, dementia, obstructive uropathy, and reflux uropathy, and had an order for an indwelling catheter. The resident's assessments and medical records consistently documented the presence of the catheter and the need for substantial assistance with activities of daily living due to severely impaired cognitive skills. Despite this, the baseline care plan created at admission did not include any information regarding the resident's indwelling catheter. Interviews with facility staff, including the MDS nurse and the Assistant Director of Nursing, confirmed that the baseline care plan was incomplete and did not address the catheter, contrary to facility policy and procedure. This omission meant that the resident's immediate care needs related to the indwelling catheter were not documented in the baseline care plan.
Failure to Develop and Implement Person-Centered Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including generalized anxiety disorder and dementia, there was an active order for olanzapine to manage psychosis and agitation. Despite this, a review of the resident's care plans revealed that no care plan was created to address the use of olanzapine, including interventions to prevent or manage potential adverse effects. The Director of Nursing confirmed that a care plan should have been developed to guide staff in managing the medication's side effects. For another resident admitted with major depressive disorder, hypertension, and atrial fibrillation, there was an order for amphetamine-dextroamphetamine to treat ADHD. The resident was assessed as having the capacity to understand and make decisions and was independent in activities of daily living. However, a review of the care plans showed that no care plan was developed for the use of the ADHD medication. Nursing staff acknowledged that a care plan was required for any medication that could alter a resident's mental state, and the Assistant Director of Nursing confirmed that a care plan should have been written for the psychotropic medication. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, including those receiving psychotropic medications. The policies also specified that behavioral interventions and monitoring for effectiveness and adverse consequences should be included. The absence of care plans for these medications meant that staff lacked documented guidance for monitoring and managing the residents' medication regimens as required by facility policy.
Failure to Update Dental Care Plan After Loss of Dentures
Penalty
Summary
The facility failed to update and revise a resident's dental care plan after the resident's upper dentures went missing. The resident, who had diagnoses including major depressive disorder, type two diabetes mellitus, and schizophrenia, was noted to have moderately impaired cognitive skills and required staff assistance for various activities of daily living, including supervision for oral hygiene. The resident's care plan for dental problems, initiated at admission, included interventions for daily oral care and dental consultations as needed, and originally indicated the resident was wearing full top dentures. After the resident reported her top dentures missing, documentation showed that a dental evaluation was performed and extractions were recommended to prepare for new dentures, but the resident declined further dental procedures. Despite this significant change, the care plan was not reviewed or revised to reflect the loss of the dentures or the resident's decision to decline further dental treatment. Interviews with facility staff confirmed that care plans are required to be reviewed and updated quarterly and after significant changes, but this was not done in this case.
Failure to Complete and Accurately Document Fall Risk Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure that fall risk assessments were completed accurately and in a timely manner for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident, who had diagnoses including metabolic encephalopathy, lack of coordination, and mild cognitive impairment, the facility did not accurately document a fall that occurred. Despite the resident being found on the floor next to her bed, the subsequent fall risk assessments incorrectly indicated that she had not fallen in the previous 90 days. Both the registered nurse and the director of nursing confirmed that this omission was incorrect and could affect the accuracy of the fall risk score. Another resident, admitted with unspecified dementia, Alzheimer’s disease, and lack of coordination, experienced a witnessed fall when sliding from a wheelchair to the floor. However, after this incident, licensed staff did not complete a fall risk assessment as required by facility policy. Both the MDS nurse and the assistant director of nursing acknowledged that a fall risk assessment should have been completed after the fall, in accordance with the facility’s procedures for assessing falls and their causes. The facility’s policies and procedures specify that after a fall, staff must complete a fall risk assessment, document appropriate interventions, and record relevant information in the resident’s medical record. In both cases, the failure to follow these procedures resulted in incomplete or inaccurate documentation of fall risk, which could impact the identification and implementation of interventions to prevent further falls.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident who required hemodialysis. Specifically, the dialysis center did not record the resident's post-dialysis weight on the communication record for a specified date. This omission was verified during record reviews and interviews with both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who confirmed that the post-dialysis weight was missing and acknowledged that the nursing staff should have contacted the dialysis center to obtain this information. The resident involved had a diagnosis of end stage renal disease and was dependent on hemodialysis, with a care plan in place that included monitoring weight and reporting significant changes to the physician. The facility's policy required documentation of dialysis treatment in the resident's medical record. Despite these requirements, the absence of the post-dialysis weight was not addressed by the nursing staff, resulting in incomplete documentation of the resident's dialysis care.
Failure to Monitor Stimulant Medication Use and Effectiveness
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the use of amphetamine-dextroamphetamine, a stimulant medication typically used to treat ADHD. The resident in question was admitted with diagnoses including major depressive disorder, hypertension, and unspecified atrial fibrillation, but did not have a documented diagnosis of ADHD. Despite being prescribed amphetamine-dextroamphetamine, there was no corresponding care plan or physician’s order to monitor for adverse effects or effectiveness of the medication. During interviews and record reviews, it was confirmed that nursing staff did not create a care plan or obtain an order to monitor the resident’s behavior or potential adverse effects related to the stimulant medication. Both the registered nurse and the assistant director of nursing acknowledged that such monitoring and care planning were required by facility policy, especially for psychotropic medications. The facility’s policies also specified the need for behavioral interventions and monitoring for effectiveness and adverse consequences, which were not implemented in this case.
Failure to Document and Accommodate Food Allergy and Preferences
Penalty
Summary
The facility failed to properly document and accommodate a resident's egg allergy and food preferences, resulting in deficiencies in care. The resident, who had a documented allergy to eggs in multiple records including the admission record, history and physical, dietary interview, and care plan, did not have this allergy indicated on her meal tray ticket. Observations confirmed that the tray ticket only listed eggs as a dislike, not as an allergy, and staff interviews revealed that the allergy should have been clearly marked to prevent exposure. The dietary supervisor, registered nurse, registered dietician, and director of nursing all acknowledged that the allergy was not properly documented on the tray ticket, which could lead to the resident being served eggs. Additionally, the facility failed to provide an appropriate food substitution for the resident during breakfast when eggs were not served. On observation, the resident's breakfast tray did not contain eggs, but also lacked a protein substitute. The dietary supervisor confirmed that a protein should have been provided in place of the egg and subsequently added yogurt to the tray after the deficiency was noted. The resident expressed a preference for yogurt, and the dietary supervisor emphasized the importance of protein in the diet. The facility's own policy and procedure on food allergies and intolerances required that all resident-reported food allergies be documented in assessment notes, care plans, and diet slips, and that appropriate substitutions be offered for foods that cannot be eaten. Despite these policies, the resident's egg allergy was not properly communicated on the tray ticket, and a suitable substitution was not provided at breakfast, resulting in a failure to meet the resident's nutritional needs and accommodate her allergy.
Inaccurate MDS Assessments for Discharge Disposition and Active Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in inaccurate documentation of their status and diagnoses. For one resident, the MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while multiple other records, including physician orders, nursing progress notes, and the discharge summary, all documented that the resident was actually discharged to another skilled nursing facility. The MDS nurse responsible for completing the assessment acknowledged that the wrong discharge disposition was selected in error, leading to an inaccurate medical record. For another resident, the MDS assessment did not include an active diagnosis of anxiety, despite the resident's history and physical, psychiatric progress notes, and care plan all documenting anxiety as a current condition. The resident was receiving Ativan for anxiety, and the care plan specifically addressed interventions for anxiety-related behaviors. The MDS nurse confirmed that anxiety should have been included as an active diagnosis in the MDS to ensure accurate documentation of the resident's medications and diagnoses. Facility policy requires that MDS assessments be completed accurately and reflect information consistent with progress notes, care plans, and resident observations. The deficiencies identified were due to staff errors in completing the MDS, resulting in discrepancies between the MDS and other clinical documentation for both residents.
Failure to Provide Medically-Related Social Services: Missing Mobility Aid at Discharge
Penalty
Summary
The facility failed to provide medically-related social services to meet the needs of a resident by not ensuring the return or timely replacement of a missing rollator walker, a mobility aid necessary for safe ambulation. The resident, who had diagnoses including systemic lupus erythematosus, cerebral infarction, and difficulty walking, was admitted with a documented need for assistance with mobility and other activities of daily living. Upon discharge, the inventory list indicated the resident had a walker, but there was no documentation or signatures confirming the walker was returned to the resident. A review of records and interviews with the Social Services Assistant confirmed that the resident was discharged without her rollator walker and that there was no documented follow-up to obtain or replace the missing equipment. The facility's policy required the provision of adaptive equipment to maintain or improve residents' physical and psychosocial needs, but this was not followed in this case.
Inadequate Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, resulting in a deficiency. The resident, who had severe cognitive impairment and required maximum assistance for daily activities, expressed a desire to transfer to another facility. The Social Services Director (SSD) assisted in finding a new facility and informed the resident and their responsible party (RP) about the transfer. However, the SSD did not provide comprehensive information about the new facility, such as the services offered, quality measures, or details about the care providers, which is required by the facility's discharge policy. The Director of Nursing (DON) confirmed that the correct process for transferring a resident includes providing detailed information about the new facility to the resident and their RP. The facility's policy on discharging residents outlines the need to inform them about the location, size, services, and care providers at the new facility, as well as the reason for the discharge. The failure to provide this information could potentially lead to decreased quality of care and continuity of care for the resident.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party (RP) for the administration of the antipsychotic medication Olanzapine. This oversight involved a resident who was originally admitted with diagnoses including psychosis and epilepsy. The resident's Minimum Data Set indicated intact cognition and required assistance with various activities of daily living. Despite these needs, the facility administered Olanzapine for six days without obtaining the necessary informed consent from the RP, as documented in the resident's records. The deficiency was identified during a review of the resident's physician orders and informed consent forms, which showed that consent was obtained for other medications but not for Olanzapine. Interviews with a registered nurse and the administrator in training confirmed that the medication was started at the hospital and continued upon the resident's return to the facility without proper consent. The facility's policy requires informed consent for psychotropic medications, but this was not adhered to in this case, resulting in the administration of Olanzapine without the RP's informed agreement.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for seven residents, leading to deficiencies in addressing their specific medical needs. For three residents with diabetes, the facility did not create care plans for their insulin use, despite having physician's orders for insulin administration. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged the absence of care plans that should have included treatment goals, specified interventions, and evaluation dates. Another resident, who was readmitted with bipolar disorder and unspecified psychosis, was prescribed psychotropic medications such as Latuda, Seroquel, and Trazodone. However, the facility did not develop care plans for these medications, which are crucial for monitoring drug risks and ensuring the resident's care needs are met. The DON emphasized the importance of care plans in recognizing the right interventions for specific medications to manage the resident's behaviors effectively. Additionally, the facility failed to create care plans for a resident diagnosed with viral hepatitis C and two residents with urinary tract infections (UTIs) who were on antibiotics. The lack of care plans for these conditions meant that necessary interventions, goals, and communication with the care team were not outlined. The DON highlighted that care plans are essential for detailing interventions and treatments based on residents' diagnoses and medications, ensuring appropriate care and effective communication among the care team.
Medication and Fall Prevention Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for a resident with severe cognitive impairment. The resident was found with several medications left unattended on the bedside table, which were supposed to be administered at 9 a.m. The nurse responsible for administering the medications became distracted and left the medications without witnessing the resident take them. This oversight was acknowledged by the nurse and the Director of Nursing, who confirmed that the resident was not authorized to self-administer medications, and the facility's policy required nurses to observe residents taking their medications. Another deficiency involved a resident whose bed was not positioned in the lowest position as ordered by the physician for fall prevention. The resident had a history of falls and required assistance with daily activities. A Certified Nursing Assistant admitted to not following the physician's order because it was easier for the resident to stand up from a higher bed position. The Director of Nursing emphasized the importance of following physician orders to potentially reduce the severity of injuries from falls. The facility also failed to provide a high-risk resident with bilateral landing mats as ordered by the physician. The resident, who had fluctuating capacity and required assistance with mobility, was observed without the prescribed landing mats in her room. The Director of Staff Development confirmed the absence of the mats and acknowledged that no other interventions were in place to prevent falls, despite the resident's high fall risk score. The facility's policy required the implementation of a resident-centered fall prevention plan, which was not adhered to in this case.
Failure to Document Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses documented attempts of non-pharmacological interventions before administering as-needed opioid medications to a resident. This deficiency was identified for one of the 30 sampled residents, who was admitted with diagnoses including polyneuropathy and chronic pulmonary edema. The resident had moderately impaired cognition and required partial assistance for most activities of daily living. The physician's orders included hydrocodone-acetaminophen for moderate pain, but there was no documentation of non-pharmacological interventions being attempted prior to administering the medication on multiple occasions. During interviews, the Licensed Vocational Nurse and the Director of Nursing acknowledged the absence of documentation for non-pharmacological interventions before administering the opioid medication. The Director of Nursing emphasized the importance of attempting such interventions to avoid unnecessary reliance on opioid medications, which could lead to adverse side effects like increased risk for falls and sedation. The facility's policy on pain assessment and management, last reviewed in January 2024, indicated that non-pharmacological interventions might be appropriate alone or alongside medications.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the late administration of several medications for a resident with end-stage renal disease and severely impaired cognition. The resident was readmitted to the facility with multiple diagnoses, including seizure disorder, unspecified psychosis, restless leg syndrome, bipolar disorder, Parkinson's disease, and hypertension. The physician had ordered specific medications to be administered at designated times to manage these conditions. On the day of the incident, a registered nurse observed a cup of medications left on the resident's bedside table, which were supposed to be administered at 9 a.m. The nurse acknowledged that the medications should not have been left unattended and that the nurse should have ensured the resident took them. A licensed vocational nurse admitted to leaving the medications at the bedside due to being distracted by another resident needing assistance, resulting in the resident not being observed taking the medications. The facility's Director of Nursing confirmed that the medications were administered late, outside the standard protocol of administering 9 a.m. medications between 8 a.m. and 10 a.m. The facility's policy and procedure for medication administration emphasized the importance of administering medications without unnecessary interruptions and observing the resident to ensure the medications were ingested. The failure to adhere to these procedures resulted in the resident receiving her medications late, with the potential for missed doses.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for three residents, leading to potential contamination of medical equipment. For Resident 279, the indwelling catheter tubing was observed touching the floor, which was acknowledged by a Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IPN) as a risk for infection due to the floor's contamination. The facility's policy clearly stated that catheter tubing and drainage bags should be kept off the floor. Resident 7's oxygen equipment was not properly labeled or stored, as observed by a Registered Nurse (RN). The nasal cannula was found touching the floor, and both the humidifier and nasal cannula were unlabeled. The Director of Nursing (DON) confirmed that labeling and proper storage are necessary to prevent infection, as per the facility's policy on respiratory therapy infection prevention. For Resident 117, a portion of the nasal cannula tubing was found inside a trash bin, which the Assistant Director of Nursing (ADON) identified as a contamination risk. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent disease transmission. The Centers for Disease Control and Prevention (CDC) guidelines also highlighted the rapid contamination potential of floors, reinforcing the need for proper infection control measures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could delay necessary care and services. Resident 27, who was admitted with chronic obstructive pulmonary disease, difficulty in walking, and lack of coordination, was observed with a call light placed on the top edge of the bed, out of reach. The resident required assistance with various activities of daily living and did not have the capacity to understand and make decisions. The care plan for Resident 27 included an intervention to keep the call light within reach, but this was not followed. A Certified Nursing Assistant confirmed the call light's placement and acknowledged the importance of having it within reach to prevent falls. Similarly, Resident 28, diagnosed with epilepsy and asthma, was found with a call light hanging behind the bed, making it inaccessible. This resident also had moderately impaired cognition and required supervision for most activities of daily living. The care plan for Resident 28 included ensuring the call light was within reach, but this was not adhered to. A Certified Nursing Assistant confirmed the call light's improper placement. The Director of Nursing emphasized the importance of having call lights within reach to prevent residents from attempting to perform tasks unassisted, which could lead to falls.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy for a resident during medication administration via a gastrostomy tube, which violated the resident's right to privacy. Licensed Vocational Nurse 3 (LVN 3) was observed administering medications to Resident 62 without fully closing the privacy curtain around the resident's bed, leaving it open at the foot. This action was confirmed during an interview with LVN 3, who acknowledged not closing the curtain completely. Resident 62 was admitted to the facility with diagnoses including aphasia, hemiplegia, hemiparesis, and required attention to a gastrostomy. The resident had severely impaired cognition and needed maximal assistance for most activities of daily living. The facility's policy on dignity, last reviewed in January 2024, emphasized the importance of maintaining resident privacy during personal care and treatment procedures. The Director of Nursing also highlighted the significance of providing privacy to protect residents' dignity and prevent embarrassment.
Expired Food Handling Deficiency
Penalty
Summary
The facility failed to adhere to safe food handling practices by not discarding two bags of hotdog buns that were 12 days past their best by date. During a kitchen observation, a kitchen supervisor acknowledged the presence of the expired buns and stated that they were no longer safe for consumption by residents. The facility's policy on food receiving and storage, which was last reviewed earlier in the year, mandates that food should be received and stored in compliance with safe food handling practices. This oversight had the potential to expose 24 out of 121 residents to foodborne illnesses due to the consumption of potentially contaminated food.
Inaccurate MDS Assessments for Falls and Advance Directives
Penalty
Summary
The facility failed to ensure accurate assessments in the Minimum Data Set (MDS) for two residents, leading to potential delays in care and services. For one resident, the MDS inaccurately indicated that the resident had no falls since admission, despite a documented fall occurring on 3/25/2024. This resident had severely impaired cognition and required substantial assistance for activities of daily living. The inaccuracy was identified during a review with a Licensed Vocational Nurse (LVN), who acknowledged the error and emphasized the importance of accurate MDS coding for proper care planning. Another resident's MDS inaccurately reflected the presence of an advance directive, which was not the case according to the resident's Advance Directive/Physician Orders for Life-Sustaining Treatment Acknowledgement form. This resident had intact cognition and required moderate assistance for daily activities. The LVN confirmed the MDS error and highlighted the significance of knowing whether a resident has an advance directive to ensure care aligns with the resident's preferences, especially if the resident loses decision-making capacity. The Director of Nursing reiterated the importance of accurate MDS assessments for effective care planning.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident hit another, resulting in physical injuries. On the specified date, Resident 1, who had diagnoses including seizures and schizophrenia and was noted to have severely impaired cognition, physically assaulted Resident 2. This incident occurred despite Resident 1's known inability to understand or make decisions independently, as documented in their medical records. Resident 2, who also had severely impaired cognition due to dementia and schizophrenia, sustained a cut, redness, and swelling around the left eye as a result of the altercation. The incident was witnessed by an LVN, who intervened to separate the residents. The LVN observed that Resident 2 had discoloration around the left eye, which was not present before the altercation, indicating that Resident 1 likely hit Resident 2 during the struggle. The facility's Director of Nursing and the Administrator in Training confirmed that the incident constituted physical abuse and acknowledged that the facility failed to protect Resident 2 from such abuse. The facility's policy on abuse prevention, which mandates that residents be free from abuse, was not followed, as evidenced by the failure to prevent the altercation and subsequent injury to Resident 2.
Failure to Enforce Smoking Policy
Penalty
Summary
The facility staff failed to follow the facility's smoking policy for two residents when they allowed one resident to share a cigarette with another. Resident 3, who has moderately impaired cognition and requires moderate assistance with mobility, was observed giving a cigarette to Resident 4, who also has moderately impaired cognition and requires supervision with mobility. This incident occurred in the smoking patio, and the staff member present, referred to as Gatekeeper, did not prevent the sharing of the cigarette despite knowing that it was against the facility's policy. Interviews with the Gatekeeper, Activities Supervisor, and Director of Nursing confirmed that the facility's policy prohibits residents from sharing smoking items. The facility's policy, titled 'Smoking Policy - Residents,' explicitly states that residents are not permitted to give smoking items to other residents. The failure to enforce this policy has the potential to place residents at risk for accidents such as burns.
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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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