Studebaker Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 13226 Studebaker Rd, Norwalk, California 90650
- CMS Provider Number
- 056425
- Inspections on file
- 52
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Studebaker Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of stroke and PTSD, who was cognitively intact and required maximal assistance with ADLs, reported concern after a CNA cursed in the resident’s presence while providing care. The CNA acknowledged spilling water in the room and using foul language, and the DON confirmed the resident stated she did not appreciate the outburst. Facility policies stated residents have the right to be free from abuse and defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing.
A cognitively intact resident with ALS and major depressive disorder, dependent for ADLs, reported that a CNA made a sexually inappropriate pelvic thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation and which made him angry. The resident informed the DSD, a mandated reporter, of the incident, but the DSD did not report the allegation to CDPH or other required authorities. The DON later acknowledged that the allegation constituted abuse and should have been reported immediately in accordance with the facility’s abuse policy, which requires reporting all abuse allegations within two hours to the state survey agency, law enforcement, and the Ombudsman.
A resident with ALS and major depressive disorder, who was cognitively intact and dependent for ADLs, reported that a CNA made an inappropriate sexual thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation. The resident informed the DSD, who acknowledged being a mandated reporter but did not report or initiate an investigation. A CNA and the DON both characterized such conduct as a form of abuse that should be reported. Facility P&Ps required prompt, thorough investigation of abuse allegations and defined abusive conduct to include disparaging or derogatory gestured language, but these procedures were not followed in this case.
A resident with multiple serious health conditions experienced a delay in care after abnormal lab results were not promptly communicated to the physician as required. Nursing staff failed to document or directly notify the physician, instead sending lab results via text message, which was not the physician's preferred method. As a result, the resident's transfer to a hospital for treatment of severe dehydration, hypernatremia, and acute kidney injury was delayed.
A LVN did not document abnormal lab results or their communication to a physician for a resident with complex medical conditions, despite facility policy requiring such documentation. Instead, the LVN texted photos of the lab results to the physician and did not enter this information into the medical record, resulting in incomplete and inaccurate records and potential disruption of care continuity.
A resident with ALS, diabetes, and major depressive disorder, who was cognitively intact, filed multiple grievances about care and rights violations. Despite repeated requests, neither the resident nor their responsible party received written updates or resolutions, as required by facility policy. Staff confirmed that only verbal updates were given, leading the resident to escalate concerns to the state health department.
A resident with ALS, diabetes, and depression experienced symptoms including headache, cough, congestion, and fear of choking, but the nurse only notified the physician about cough and congestion via text, omitting key symptoms. The physician did not respond during the nurse's shift, and there was no follow-up call or escalation to the DON or Medical Director. The resident's condition worsened, leading to a hospital transfer and diagnosis of pneumonia and hypoxia. Documentation of communication and events was incomplete.
A resident with ALS, diabetes, and depression experienced cough, congestion, and fear of choking overnight. The nurse notified the physician by text about some symptoms but did not communicate the resident's fear of choking or shortness of breath. The physician did not respond for over eight hours, and the nurse did not escalate the issue to the DON or Medical Director as required by policy. The resident's family later called 911, and the resident was hospitalized with pneumonia and hypoxia.
A resident with ALS and intact cognition was not treated with dignity when a CNA removed his glasses without consent during care, leading to feelings of violation and distrust. Additionally, the resident was not provided with an admission packet or orientation, leaving him unaware of his rights and facility policies. Staff interviews confirmed these omissions, which resulted in the resident's confusion and lack of trust in the care team.
A resident with ALS, fully dependent on staff for transfers, was injured when a mechanical lift tipped and the sling bar struck the resident's head during a transfer. The incident occurred without a required physician order for lift use, resulting in head and chest contusions and hospital evaluation.
A resident who was alert and continent, but dependent on staff for toileting hygiene due to ALS, was not properly assessed or placed on a toileting program. Staff failed to assist the resident in a timely manner to use a urinal, instead encouraging use of an incontinence brief for staff convenience, which led to the resident being left in soiled conditions and feeling humiliated. Facility policies requiring continence assessment and individualized care planning were not followed.
A resident with ALS, depression, and diabetes refused to accept medications from an LVN due to concerns about respect. The LVN pre-charted the medications in the MAR before administration, and after the resident refused, another LVN prepared and administered new medications. The MAR was not updated to reflect the correct nurse or the resident's refusal, resulting in inaccurate documentation.
The facility failed to secure controlled drugs, including Oxycodone and Lorazepam, as per policy. A resident's Oxycodone was found in an unlocked drawer, and Lorazepam was not locked in the medication refrigerator. This involved residents with fibromyalgia and epilepsy, respectively.
The facility failed to follow professional standards for food service safety, as observed in the improper labeling and dating of food items and inadequate cleaning of kitchen equipment. Sack lunches for residents going out for dialysis were not labeled with preparation dates, and a container of liquid eggs was found open without an open date. Additionally, a can opener had a black sticky substance, indicating it was not cleaned as required. These deficiencies could lead to pathogen exposure and foodborne illnesses.
The facility failed to ensure that two residents had completed advance directive acknowledgments and POLST forms in their medical records. One resident, with developmental disorder and psychosis, lacked decision-making capacity, and the forms were sent to the Regional Center but not followed up. Another resident, with multiple diagnoses and severe cognitive impairment, also lacked a completed advance directive. The facility's policy requires these forms to be maintained, but the lack of follow-up and documentation led to incomplete records, potentially delaying care during emergencies.
The facility failed to implement comprehensive care plans for two residents, one with an intellectual/developmental disability and another using a bipap machine. The first resident lacked a care plan addressing their IDD, while the second resident's care plan did not cover bipap use, leading to issues with the humidifier. The facility's policy requires person-centered care plans, but these were not developed, potentially affecting the residents' quality of life.
A resident with end-stage renal disease and diabetes did not receive adequate dialysis care. The facility failed to update the resident's hemodialysis schedule, document refusals, or notify the MD of missed sessions. Out-of-range A1C levels were not reported, and the resident did not receive appropriate snacks on dialysis days. These deficiencies highlight a breakdown in communication and documentation within the facility.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. One resident with schizophrenia and other mental health disorders had several medications not documented as administered, while another resident with dementia and psychotic disorder also experienced lapses in medication administration. The Director of Nursing confirmed that physician orders should always be implemented as ordered.
The facility failed to implement nonpharmacological interventions for two residents prescribed PRN psychotropic medications. One resident with schizophrenia and dementia exhibited aggressive behaviors and was given Lorazepam without prior nonpharmacological measures. Another resident with dementia and anxiety was prescribed Xanax PRN without such interventions. Interviews confirmed the absence of these measures, contrary to the facility's policy.
Two residents in an LTC facility experienced medication administration errors, leading to a 23.08% error rate. One resident received enteric-coated aspirin instead of chewable aspirin, while another received five medications crushed together, contrary to facility policy. Staff failed to follow physician orders and best practices for medication administration.
The facility failed to properly label and store medications, affecting two residents. Bubble packs for medications lacked necessary instructions, insulin vials were not dated, and expired Vitamin K was found in the emergency kit. Saline solutions were stored insecurely, contrary to facility policies.
The facility failed to ensure proper infection control practices, as staff did not follow Enhanced Barrier Precautions or perform necessary hand hygiene and glove changes during resident care. An LVN did not wear an isolation gown while administering medications through a G-tube, and CNAs neglected hand hygiene and PPE use, risking infection spread among residents with severe cognitive impairments and those on dialysis.
A CNA failed to maintain a resident's dignity during meal assistance by standing over and rushing the resident to eat, despite being advised to sit at eye level. The resident, with developmental disorder and dysphagia, requires meal assistance. Facility policy emphasizes feeding with dignity, which was not followed in this instance.
A resident with dementia and no decision-making capacity signed Medicare-related documents without proper assessment or involvement of their responsible party. The facility's BOM did not verify the resident's capacity or consult nursing staff, leading to the resident's family being uninformed and concerned about potential costs and loss of appeal rights.
A facility failed to itemize a resident's belongings upon admission, resulting in lost items. The resident, with conditions including end-stage renal disease and major depressive disorder, reported missing a blanket and clothes. The Social Services Director and Registered Nurse Supervisor acknowledged the oversight, which violated the facility's policy requiring documentation of personal belongings upon admission.
A resident with multiple health conditions was transferred to a hospital due to vomiting and shortness of breath, but the facility failed to complete the necessary transfer form. This omission led to the receiving facility lacking essential information, as confirmed by interviews with the RN Supervisor and DON.
Two residents with dementia were involved in a physical altercation due to the facility's failure to implement their care plans. One resident, with a history of aggression, was not placed near the nursing station for monitoring, allowing them to approach another resident's bedside. The second resident, also with a history of aggression, scratched the first resident during the altercation. Additionally, the first resident missed three doses of Memantine, a dementia medication, which may have contributed to their behavior.
A facility failed to follow a pharmacy recommendation to repeat a Hemoglobin A1C test for a resident with diabetes and end-stage renal disease. Despite the pharmacy consultant's advice, the test was not ordered, and results were not communicated to the MD. Both the RN Supervisor and DON acknowledged the oversight, which was contrary to the facility's policy requiring notification of abnormal results.
Two residents with histories of aggressive behavior were involved in a physical altercation due to the facility's failure to monitor one resident as required by their care plan. Despite a care plan intervention to keep the resident near the nursing station for closer supervision, they were not placed accordingly, leading to the incident.
A resident with Parkinson's disease was not readmitted to the facility after hospitalization due to combative behavior and drug paraphernalia possession. Despite being cleared for return by the GACH, the facility did not honor the bed-hold policy, resulting in the resident staying at the hospital for two extra days. The facility's DON suggested the resident needed a substance abuse program, and the resident's bed was given away.
A resident with cognitive impairment and mobility issues was left in soiled incontinence briefs for over two hours, despite informing a CNA of the need for care. The CNA delayed assistance due to lunch service, and the resident remained unattended even after lunch trays were cleared. Facility staff confirmed the availability of a buddy system and team leaders to assist when needed, but these resources were not utilized, resulting in neglect of the resident's hygiene needs.
A facility failed to ensure proper management of psychotropic medications for two residents. One resident lacked a medical diagnosis for Depakote use, while another had PRN psychotropic orders without specified duration, frequency, or non-pharmacological interventions. Both residents did not have informed consent documented for their medications, contrary to facility policies.
A resident with cellulitis and stasis dermatitis did not receive prescribed medications on time due to a lack of communication and verification processes in the facility. Medications were delivered but not administered promptly, with Ciprofloxacin given six days late and Ammonium Lactate five days late. Staff interviews revealed unawareness of orders and absence of a system to verify medication deliveries against physician orders.
A resident with bipolar and schizoaffective disorders eloped from an LTC facility due to inadequate supervision. The resident was last seen in his room and was reported missing after staff failed to monitor the front entrance effectively. The resident was found 14 hours later, highlighting lapses in the facility's elopement prevention policy and staff coverage.
A resident, discharged AMA and no longer under facility care, had a gastrostomy tube removed at the LTC facility by a PA in the DON's office without proper orders. The resident, with dysphagia and intact cognition, was initially admitted with a GT. After discharge, the resident's responsible party returned to the facility for the procedure due to safety concerns, bypassing the facility's admission policy requiring physician orders.
A facility failed to ensure dermatology consultation notes were available in a resident's medical record, leading to delayed treatment. The resident, admitted with cellulitis, returned from a dermatology appointment with no new orders documented. Staff interviews revealed a lack of follow-up to obtain the consultation notes, which the DON confirmed, acknowledging the risk of missed treatment. Facility policy requires records to be legible and readily available, which was not followed.
A resident tested positive for Candida Auris, but the facility delayed initiating a Change of Condition form and obtaining physician's orders for infection prevention measures. Despite being informed by a hospital, the facility did not implement Enhanced Barrier Precautions until the following day, placing other residents and staff at risk. The facility's policies require immediate action for infection control, which was not followed in this case.
The facility failed to maintain a safe and homelike environment in a shower room, with eight missing and two cracked tiles observed. The Maintenance Supervisor admitted the tiles had been in disrepair for six months, posing a risk of accidents and germ exposure. The Administrator acknowledged the safety risk, which contradicts the facility's policy for a safe and comfortable environment.
The facility failed to conduct required IDT meetings for four residents with physician orders to go out on pass, violating their rights to participate in care planning. Despite having intact cognition and decision-making capacity, the residents were not assessed by the IDT as per facility policy, which the DON was unaware of.
A resident did not receive prescribed eye medications for four days after cataract surgery due to the facility's failure to clarify postoperative orders with the physician. Despite attempts by a nurse to contact the physician, the orders were not confirmed, delaying the administration of necessary medications.
Failure to Protect Resident From Verbal Abuse During Care
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when a CNA used foul language in the resident’s presence during care. The resident had been admitted with diagnoses including cerebral infarction and PTSD, and an MDS assessment indicated intact cognition with a need for maximal assistance with toileting, bathing, and dressing. A Change in Condition note documented that the resident expressed concern about the CNA’s use of foul language in her presence. The facility’s investigation summary later confirmed that the CNA used an inappropriate word while inside the resident’s room. In an interview, the CNA stated that while in the resident’s room she spilled a cup of water and cursed in front of the resident, acknowledging that this could make the resident feel upset and uncomfortable. The DON also confirmed that the CNA used foul language in front of the resident and that the resident reported she did not appreciate the CNA blurting that out in front of her. The facility’s abuse prevention and prohibition policy stated that each resident has the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff. Another facility policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Report Resident’s Allegation of Sexually Inappropriate Staff Conduct
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) as required under F609. A cognitively intact resident with diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, who was dependent for ADLs, reported that a CNA made an inappropriate sexual gesture while providing personal care. The resident stated that the CNA thrust his pelvic area against a gray stool in the room in a way the resident found offensive and felt was mocking his sexual orientation as a gay man, which made him feel angry. The resident reported this incident to the Director of Staff Development (DSD), whom he identified as a mandated reporter. The DSD confirmed in interview that the resident had reported the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle because he is gay. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported for the resident’s safety and to ensure a proper investigation, but she did not report it. The DON stated that the DSD should have reported the allegation immediately, that the allegation was a form of abuse, and that it should have been reported so a proper investigation could be conducted and the resident could be monitored for emotional distress. Review of the facility’s Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after forming a suspicion, to the state survey agency, law enforcement, and the Ombudsman, which did not occur in this case.
Failure to Investigate Resident’s Allegation of Sexual Abuse Gesture
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Prohibition Program by not investigating an allegation of sexual abuse made by a resident. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, had intact cognition per a recent MDS and was dependent for ADLs. During an interview, the resident reported that a CNA made an inappropriate sexual thrusting gesture with his pelvic area on a stool in the resident’s room, which the resident found offensive and perceived as mocking his sexual orientation as a gay man. The resident stated he reported this incident to the Director of Staff Development (DSD) and believed, as a mandated reporter, the DSD should have reported the allegation. The DSD confirmed in an interview that the resident had informed her about the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle, but she did not report the allegation. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported. Another CNA stated that any inappropriate sexual thrusting gesture is considered a form of abuse and should be reported for resident safety. The DON stated the DSD should have reported the allegation immediately, that the conduct described was a form of abuse, and that it could have made the resident feel offended and embarrassed. Review of the facility’s abuse-related P&Ps showed that verbal abuse includes gestured language with disparaging or derogatory terms and that the facility is required to promptly and thoroughly investigate reports of resident abuse, including suspending accused staff until the investigation is complete. These required investigative steps were not initiated in response to the resident’s allegation.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
A deficiency occurred when abnormal laboratory results for a resident were not reported to the resident's physician in a timely manner, nor were instructions for care obtained promptly. The laboratory results, which included significant abnormalities such as elevated sodium, blood urea nitrogen (BUN), creatinine, and liver enzymes, were received by the facility in the afternoon. Despite the facility's policy requiring notification of abnormal results to the physician, there was no documentation that the physician was notified on the day the results were received. The resident had a complex medical history, including acute kidney failure, cerebral infarction, and congestive heart failure, and was unable to make reasonable decisions according to the Minimum Data Set. The abnormal lab results indicated severe dehydration, hypernatremia, and impaired kidney and liver function. Nursing staff on the relevant shifts failed to document follow-up or notification of the physician. One nurse texted the results to the physician, contrary to the physician's stated preference for phone calls, and did not document the communication in the resident's progress notes. The physician acknowledged receipt of the text but did not review the results at that time, and no further action was taken until the following day. The delay in notifying the physician and obtaining care instructions resulted in a delay in transferring the resident to an acute care hospital for evaluation and treatment. When the physician was finally contacted the next day, the resident was transferred and treated for severe dehydration, hypernatremia, hypotension, and acute kidney injury. Interviews with staff and the physician confirmed that the facility's expectations and the physician's preferences for communication were not followed, leading to the delay in care.
Failure to Document Lab Results and Physician Communication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document laboratory results and the communication of those results for a resident with multiple serious diagnoses, including acute kidney failure, cerebral infarction, and congestive heart failure. The resident was unable to make reasonable and consistent decisions, as indicated by their Minimum Data Set assessment. Physician orders required several lab tests, which were performed and returned with multiple abnormal results, including elevated white blood cell count, abnormal electrolyte levels, high blood glucose, impaired kidney function, and abnormal liver function tests. Despite the receipt of these abnormal lab results, there was no documentation in the resident's nursing progress notes to indicate that the results were communicated to the physician on the day they were received. The LVN stated that she printed the lab results, took photos, and texted them to the physician, believing that this method was sufficient and that further documentation in the medical record was unnecessary. This practice was contrary to facility policy, which required all care and communications, including lab data and their disposition, to be documented in the resident's medical record. The Director of Nursing confirmed that it was the responsibility of all licensed nurses to document all care provided, including communication with physicians, in the resident's medical record. Facility policies reviewed also emphasized the need for accurate and complete documentation of residents' status, care, and laboratory data in the medical record. The lack of documentation resulted in an incomplete and inaccurate depiction of the resident's well-being and had the potential to disrupt continuity of care.
Failure to Provide Written Grievance Outcomes to Resident
Penalty
Summary
The facility failed to provide the results of multiple grievances filed by a resident and/or their responsible party. The resident, who was diagnosed with amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, was cognitively intact and able to communicate effectively. Despite submitting several grievances regarding perceived violations of resident rights and substandard care, neither the resident nor their responsible party received written updates or resolutions regarding the status of these grievances, even after repeated requests. Documentation reviewed showed that the facility investigated the grievances, but there was no indication that the outcomes or resolutions were communicated in writing to the resident or their responsible party. Interviews with facility staff confirmed that while some outcomes were discussed verbally, the resident's specific request for written updates was not honored. The Social Services Director acknowledged that written communication should have been provided, and the Director of Nursing stated that timely updates are a resident right. The facility's own grievance policy required that residents or their representatives be informed of the findings and any corrective actions in a timely manner. However, the lack of written communication regarding the resolution of grievances led to the resident feeling stressed, helpless, and distrustful of the facility. The resident escalated the complaints to the state health department due to the lack of response from the facility.
Failure to Notify Physician of Complete Change of Condition and Inadequate Follow-Up
Penalty
Summary
The facility failed to ensure timely and complete communication with a resident's physician regarding a change of condition. A resident with diagnoses including ALS, diabetes type 2, and major depressive disorder experienced symptoms such as headache, cough, congestion, and expressed fear of choking and shortness of breath. The nurse on duty documented the resident's complaints and administered medications for headache and sore throat, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent two text messages to the physician during the night shift, but did not receive a response during her shift and did not follow up by calling the physician, the DON, or the Medical Director as required by facility policy. The nurse endorsed the resident's care to the oncoming nurse without further escalation. The physician eventually responded to the text messages over eight hours later, but was not made aware of the full extent of the resident's symptoms, specifically the fear of choking and shortness of breath, which would have prompted different interventions. The resident remained anxious and symptomatic throughout the night, ultimately leading to the family calling 911 and the resident being transferred to a hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Documentation was incomplete regarding the time, method of communication, and the content of the interaction with the physician, making it difficult to ascertain the sequence of events related to physician contact and response.
Failure to Ensure Timely Physician Response to Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician responded in a timely manner to a resident's change of condition. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, began experiencing symptoms such as headache, cough, congestion, and expressed fear of choking during the night shift. The resident was cognitively intact and able to communicate his symptoms and concerns, including shortness of breath and anxiety about lying down due to fear of choking. The nurse on duty administered medications for headache and sore throat, and documented the resident's complaints, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent text messages to the resident's physician at two points during the night shift, but the physician did not respond until over eight hours later, after the shift had ended. The nurse did not escalate the situation by contacting the Director of Nursing (DON) or the Medical Director when the physician failed to respond, as required by facility policy. The resident continued to experience symptoms and anxiety throughout the night, remaining upright to ease breathing, and felt that the nursing staff did not believe the severity of his symptoms. The following morning, the resident's family called 911, and the resident was transferred to a general acute care hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Interviews with the resident, the nurse, the physician, and the DON confirmed that the physician was not informed of the full extent of the resident's symptoms, particularly the fear of choking and shortness of breath. The physician stated that he would have ordered additional interventions if he had been made aware of these symptoms. Facility policy required immediate escalation to the DON or Medical Director if the attending physician could not be reached, but this was not done. Documentation and interviews confirmed the delay in physician response and the lack of appropriate escalation.
Failure to Ensure Resident Dignity and Inform Resident of Rights
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) removed a resident's glasses from his hands without his permission while turning him in bed. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes, was cognitively intact and able to make his own decisions. The CNA did not obtain consent before taking the resident's personal belonging, and the resident reported feeling violated and distrustful of the staff as a result. The Director of Nursing (DON) and the Administrator both acknowledged that staff should not remove personal items from residents without permission, and the facility's policy confirmed this requirement. Additionally, the facility failed to provide the resident with an admission packet, which included the resident's bill of rights and information about facility policies and procedures. The Admission Coordinator admitted that the resident had not received this information or an orientation, despite having been in the facility for over ten days. The resident expressed confusion about the facility's rules and expectations and stated that he was not informed about his rights or the facility's policies, which contributed to his feelings of distrust and resistance toward staff. Interviews with facility staff confirmed that it was the responsibility of the Admission Coordinator to provide the admission packet and orientation, but all staff were responsible for ensuring residents understood their rights and facility policies. The facility's policies and procedures required that residents be treated with dignity and respect, and that they be fully informed about their rights and the facility's expectations. The failure to follow these policies resulted in the resident being unaware of his rights and feeling disrespected and confused.
Resident Injury During Mechanical Lift Transfer Without Physician Order
Penalty
Summary
A deficiency occurred when a resident diagnosed with amyotrophic lateral sclerosis (ALS), who was dependent on staff for activities of daily living, was injured during a transfer from bed to wheelchair using a mechanical lift. The resident, who was cognitively intact and at risk for falls and injuries, was being assisted by four staff members when the mechanical lift tipped to the side as the resident leaned back into the sling. During the process of detaching the sling from the lift, the sling bar struck the resident on the forehead, resulting in pain and subsequent transfer to a general acute care hospital for evaluation and treatment. The resident was found to have head and chest contusions and was treated for pain before returning to the facility. The facility's policy required a physician's order for the use of a mechanical lift, but review of the clinical records revealed that no such order was present for this resident. The Director of Nursing confirmed that the absence of a physician's order and the failure to ensure the resident's safety during the transfer led to the injury. The incident was documented in the resident's care plan and clinical records, and the facility's policy on mechanical lift use was not followed.
Failure to Provide Timely Toileting Assistance and Maintain Dignity for Continent Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident who was alert, continent of bowel and bladder, and at high risk for pressure ulcer development. Nursing staff did not assist the resident in a timely manner to use the urinal, which was necessary to maintain bladder continence. Instead, the resident was encouraged to use an incontinence brief for staff convenience, as staff were busy with other residents, resulting in the resident being left in soiled conditions and experiencing embarrassment and discomfort. The resident's care plan and Interdisciplinary Team (IDT) assessment were not implemented to address his toileting needs. The resident was not assessed for a toileting program upon admission, and his toileting habits and needs were not discussed with him. Staff did not inquire about his continence status, and he was admitted wearing an incontinence brief, leading to the assumption that he was incontinent. The resident required assistance with holding the urinal and cleaning himself due to his medical condition, but staff only responded to his needs when he specifically requested help, and there was no scheduled toileting program in place. Interviews with staff and review of facility policies confirmed that the resident's continence status was not properly assessed or documented, and a care plan addressing his bowel and bladder needs was not developed. The lack of timely assistance and failure to respect the resident's dignity resulted in the resident feeling humiliated and increased his risk for skin breakdown. Facility policies required continence assessments and individualized care plans, but these were not followed in this case.
Inaccurate Medication Administration Documentation Due to Improper Charting and Resident Refusal
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document medication administration for a resident with amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes. The resident, who was cognitively intact and able to make decisions, refused to accept medications from one LVN due to concerns about dignity and respect. The LVN prepared the medications and pre-charted their administration in the Medication Administration Record (MAR) before actually giving them to the resident. When the resident refused to take the medications from the first LVN, the medications were handed to a second LVN. The resident also refused to take the medications prepared by the first LVN, leading the second LVN to waste those medications and prepare a new set in the resident's presence, which the resident then accepted. Despite this, the MAR reflected the first LVN's initials for the administration, and the second LVN did not update the record to accurately show who administered the medications. Interviews with both LVNs confirmed that the first LVN pre-charted the medications and did not document the resident's refusal as required by facility policy. The second LVN acknowledged not correcting the MAR to reflect the actual administration. The facility's policy and job descriptions require accurate, timely documentation by the nurse who administers medications, including proper notation of refusals and the identity of the administering nurse. This failure resulted in inaccurate documentation of medication administration for the resident.
Failure to Secure Controlled Drugs
Penalty
Summary
The facility failed to ensure proper safeguards for controlled drugs, leading to potential risks of theft, loss, and unauthorized consumption. Specifically, the facility did not double lock Oxycodone Hydrochloride 5 mg, a narcotic for pain relief, belonging to a resident. The medication was found in an unlocked drawer in the medication room, contrary to the facility's policy requiring double locking of Schedule II medications. The resident was admitted with a diagnosis of fibromyalgia and was alert and oriented at the time of the incident. Additionally, the facility did not secure Lorazepam, a Schedule IV drug used for treating anxiety, in a locked medication refrigerator as per the facility's policy. The medication refrigerator's padlock was found lying on top of the refrigerator, leaving the medication accessible. This oversight involved another resident with epilepsy, who had severely impaired cognition and required substantial assistance with daily activities. The Director of Nursing acknowledged the failure to secure these medications properly during interviews.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and handling. During an observation and interview with the Dietary Supervisor (DS), it was noted that five sack lunches prepared for residents going out for dialysis lacked labels indicating the preparation date. Additionally, a 32-ounce container of pasteurized liquid whole eggs in the walk-in refrigerator was found open without an open date, which the DS confirmed should have been labeled to ensure freshness and proper discard timing. DA 1, who prepared the lunches, acknowledged the oversight in not dating the lunches. Further inspection revealed a large stationary can opener with a black sticky substance on its blade and base, indicating inadequate cleaning. The DS confirmed the presence of the substance and acknowledged the need for daily cleaning of the can opener. A review of the facility's policy and procedure documents indicated that the can opener should be sanitized between uses and that all food storage products should be labeled and dated. These practices, or lack thereof, had the potential to expose residents to pathogens and increase the risk of foodborne illnesses.
Failure to Complete Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 89 and Resident 2, had completed advance directive acknowledgments and POLST forms in their medical records. Resident 89, who was admitted with developmental disorder and psychosis, lacked the capacity to make decisions. The Social Service Director (SSD) stated that forms were sent to the Regional Center for completion but had no documentation to prove follow-up. The Medical Records Director (MRD) confirmed that the forms were faxed but had not received a response, leaving the advance directives incomplete in the resident's medical record. Resident 2, diagnosed with mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction, was also found to be severely cognitively impaired and dependent on staff for self-care. The SSD indicated that paperwork was sent to the Regional Center for the advance directive acknowledgment form, but there was no record of when the fax was sent. The Director of Nursing (DON) emphasized the importance of having these forms to ensure proper treatment during emergencies. The facility's policy and procedure on advance directives require that residents be informed of their rights to execute an advance directive upon admission, and a copy should be maintained in their medical records. The policy also mandates that the Social Service Designee educate residents and families about healthcare decision-making and maintain communication to ensure resident self-determination. However, the lack of follow-up and documentation resulted in the failure to have completed advance directives for the residents, potentially delaying care and treatment during emergencies.
Failure to Implement Comprehensive Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 2, who has an intellectual/developmental disability (IDD), did not have a care plan addressing their specific needs. The resident was admitted with multiple diagnoses, including mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction due to thrombosis. Despite these conditions, the comprehensive care plans did not focus on the resident's IDD, likes, and dislikes. Interviews with the Registered Nurse Supervisor and the Director of Nursing highlighted the importance of a tailored care plan for communication, activities of daily living, and psychosocial needs, which were not addressed for Resident 2. Resident 50, who uses a bipap machine, also lacked a comprehensive care plan for their specific needs. The resident was admitted with diagnoses including paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, and amyotrophic lateral sclerosis. The resident reported issues with the bipap machine's humidifier not being refilled by staff, causing distress and requiring the resident to set an alarm to check the humidifier at night. The MDS Coordinator confirmed the absence of a care plan for bipap use and emphasized the need for staff to conduct regular checks and interventions to ensure the resident's needs were met. The facility's policy on care planning requires a comprehensive, person-centered care plan for each resident based on their assessed needs. However, the facility failed to develop and implement such plans for Residents 2 and 50, potentially affecting their quality of life and well-being. The Director of Nursing acknowledged the importance of individualized care plans to guide staff in meeting each resident's unique needs, which was not achieved in these cases.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's medical records were not updated to reflect a change in the hemodialysis schedule, which was reduced to twice a week per the resident's preference. This change was not documented by the Licensed Vocational Nurse, who admitted to forgetting to chart the new schedule. Additionally, the resident's refusal to attend hemodialysis sessions on multiple occasions was not documented, and no follow-up appointments were scheduled. The medical doctor was not notified of these refusals, and there was no monitoring of the resident post-refusal. The facility also failed to report out-of-range Hemoglobin A1C levels to the medical doctor. The resident's A1C levels were significantly higher than normal on two occasions, but the physician was not informed to obtain further orders or recommendations. This lack of communication and documentation could have impacted the resident's diabetes management and overall health. Furthermore, the facility did not provide appropriate snacks for the resident on hemodialysis days. The resident reported not receiving the necessary snacks, only a protein drink, which contradicted the dialysis center's recommendations. The facility lacked a system to track and document the provision of snacks, and the kitchen was closed during the resident's early morning dialysis sessions, leading to inadequate nourishment. This oversight could have resulted in potential health issues for the resident during dialysis.
Medication Administration Deficiency for Two Residents
Penalty
Summary
The facility failed to administer prescription medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 20, who was admitted with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and dementia, had several medications not documented as administered in November 2024. These medications included Mirtazapine, Vitamin C, Vitamin D, Colace, multivitamin, Sucralfate, and Quetiapine. The Minimum Data Set (MDS) for Resident 20 indicated severely impaired cognitive skills for daily decision-making, requiring assistance with various activities of daily living. Similarly, Resident 75, admitted with diagnoses of dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder, also experienced lapses in medication administration. The Medication Administration Record (MAR) for November 2024 showed that doses of Atenolol, Buspirone, Fluoxetine, Memantine, and Olanzapine were not documented as given. The MDS for Resident 75 indicated intact cognitive skills for daily decision-making, with varying levels of assistance required for daily activities. The Director of Nursing confirmed that physician orders should always be implemented as ordered, including medication administration, as per the facility's policy and procedure.
Failure to Implement Nonpharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to develop and implement nonpharmacological interventions for two residents who were prescribed PRN psychotropic medications. Resident 20, diagnosed with schizophrenia, anxiety disorder, major depressive disorder, and dementia, exhibited physical and verbal aggressive behaviors. Despite these behaviors, the facility did not have nonpharmacological measures in place before administering Lorazepam as needed for anxiety. Similarly, Resident 75, with diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder, was prescribed Xanax PRN for anxiety without prior nonpharmacological interventions. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of nonpharmacological measures for both residents before administering PRN psychotropic medications. The facility's policy on behavior management, which mandates the use of nonpharmacological interventions before pharmacological ones, was not followed. This oversight had the potential to result in the unnecessary use of medications, placing the residents at risk of medication side effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications appropriately for two residents, resulting in a medication error rate of 23.08%. Resident 9, who was admitted with a history of transient ischemic attacks and cerebral infarction, was supposed to receive chewable aspirin for stroke prophylaxis. However, during the medication pass, Licensed Vocational Nurse (LVN) 2 administered enteric-coated aspirin instead of the prescribed chewable aspirin. This error was confirmed by Registered Nurse Supervisor (RN) 1, who emphasized the importance of following physician orders. Resident 16, diagnosed with dementia, hypertension, and psychosis, was observed receiving five medications crushed together and mixed with applesauce by LVN 3. The medications included metoprolol, Valsartan, Quetiapine, Docusate sodium, and Escitalopram. The facility's policy and procedure indicated that each medication should be crushed and administered separately to ensure safety and accuracy. The Director of Nursing (DON) reiterated that medications should be administered individually to identify any medication that might be spit out by the resident. These actions were contrary to the facility's policies and procedures for safe medication administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which led to several deficiencies. Two residents, one with intact cognitive skills and another with severely impaired cognitive skills, were affected by the lack of labeling on their bubble pack medications. The medications, Metoprolol and Amlodipine for one resident, and Metoprolol and Valsartan for the other, did not have the physician-ordered parameters for holding the medication based on systolic blood pressure and heart rate. Licensed Vocational Nurses confirmed that the bubble packs were not labeled with the necessary instructions, which should have been indicated for resident safety. Additionally, the facility did not label insulin vials with the date they were opened, which is necessary to ensure the medication's viability. During a medication storage check, it was observed that two vials of Lantus and one vial of Humulin R lacked the date of opening. Furthermore, Vitamin K in the emergency kit was found to be expired, and the Director of Nursing acknowledged that expired medications should not be stored for administration. The facility also failed to store saline solutions securely, as they were found in unlocked crash carts, making them accessible to unauthorized persons. The Director of Nursing stated that medications should be stored safely and securely, and expired medications should be removed from storage. The facility's policies and procedures were reviewed, indicating that medications should be stored in locked compartments and expired medications should be destroyed, but these were not followed in practice.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff members, leading to potential risks of infection spread among residents. In one instance, a Licensed Vocational Nurse (LVN) did not don an isolation gown while administering medications through a Gastrostomy tube (G-tube) for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. Despite the presence of an Enhanced Barrier Precaution (EBP) sign outside the resident's room, the LVN admitted to forgetting to wear the gown, which was necessary to prevent the spread of infection. In another case, a Certified Nurse Assistant (CNA) entered a resident's room without performing hand hygiene and did not wear personal protective equipment (PPE) while adjusting the resident's blanket. The resident was on Enhanced Barrier Protection due to a G-tube, and the CNA's actions were contrary to the facility's policy, which required hand hygiene and the use of gown, gloves, and mask to prevent infection transmission. Interviews with other staff members confirmed the necessity of these precautions, highlighting the risk of contaminating other residents with multidrug-resistant organisms (MDRO). Additionally, two CNAs failed to perform hand hygiene and change gloves during incontinence care for two residents. One resident had a history of dementia and infectious diseases, while the other was on dialysis with a permacath. Both CNAs did not change gloves between handling soiled and clean items, increasing the risk of cross-contamination. The facility's policy required glove changes and hand hygiene during such procedures, but the CNAs admitted to forgetting these steps, which could lead to the spread of infection among residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect and dignity during meal assistance. Specifically, a Certified Nurse Assistant (CNA) did not sit at eye level with the resident while assisting with feeding, instead standing over the resident and rushing her to eat. This behavior was observed during a meal service, where the resident, who has a developmental disorder and dysphagia, was being fed by CNA 6. Despite being advised by another CNA to sit down and not rush the resident, CNA 6 continued to stand and urge the resident to eat more, acknowledging later that this approach might have made the resident feel disrespected. The resident's medical records indicate she requires assistance with meals and has a consistent carbohydrate diet with pureed texture due to her condition. The facility's policy on meal assistance emphasizes feeding residents with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while assisting them. The Director of Nursing confirmed that staff should treat residents respectfully and not rush them during meals, as this could negatively impact their dignity.
Failure to Assess Mental Capacity Before Signing Medicare Documents
Penalty
Summary
The facility failed to assess the mental capacity of a resident before providing and obtaining signatures on important Medicare-related documents, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). The resident in question, who had been diagnosed with dementia and metabolic encephalopathy, was documented as having no capacity to understand and make decisions. Despite this, the resident signed the NOMNC and SNF ABN, which indicated the end of coverage for skilled services and potential costs for therapy services. The Business Office Manager (BOM) admitted to not being aware of the resident's lack of capacity and acknowledged that she should have consulted with the nursing staff before asking the resident to sign the forms. The Director of Nursing (DON) confirmed that if a resident lacks the capacity to understand and sign a form, the responsible party should be contacted to ensure they are informed and can exercise their rights, such as filing an appeal. The resident's family member was not informed about the signing of these documents, which caused concern and anxiety about potential costs and the loss of the right to appeal. The facility's policies and procedures require that a signature of acknowledgment be obtained from the beneficiary or their legal representative, and if a legal representative is involved, their authority must be verified. The facility's failure to adhere to these policies resulted in the resident and their family not being properly informed about their rights and responsibilities, potentially impacting their ability to appeal the decision regarding Medicare coverage.
Failure to Itemize Resident Belongings Leads to Loss
Penalty
Summary
The facility failed to adhere to its admission process by not itemizing a resident's personal belongings upon admission, leading to the loss of the resident's items. The resident, who was admitted with diagnoses including end-stage renal disease, major depressive disorder, and unspecified psychosis, was cognitively intact and required moderate assistance with daily activities. Upon reviewing the resident's admission record, it was found that there was no itemized list of belongings, which is a requirement according to the facility's policy. The resident reported missing items, including a blanket and clothes that were sent to the laundry and never returned. The Social Services Director was unaware of the missing items and acknowledged that the absence of an itemized list increased the risk of belongings being unaccounted for. The Registered Nurse Supervisor confirmed that the staff failed to follow the facility's admission procedure, which should have included creating an inventory of the resident's belongings. The facility's policy mandates that personal belongings be documented upon admission and that any complaints of misappropriation or theft be promptly investigated.
Failure to Document Transfer Form for Resident
Penalty
Summary
The facility failed to document a transfer form for a resident who was transferred to a general acute care hospital due to vomiting and shortness of breath. The resident, who had a history of congestive heart failure, acute respiratory failure, cerebral palsy, mild intellectual disabilities, and schizoaffective disorder, was noted to have repetitive emesis and shortness of breath. Despite the administration of medication for nausea and vomiting, the symptoms persisted, prompting an emergency medical transfer to the hospital. However, the necessary transfer form, which is crucial for communicating accurate information to the receiving facility, was not completed. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the transfer form was not filled out, which led to the receiving facility having to contact the sending facility for information. The facility's policy requires documentation of the resident's transfer, and the omission of the transfer form was acknowledged as a failure to communicate essential information about the resident's condition and care provided prior to the transfer. This oversight had the potential to delay care at the receiving facility due to the lack of information.
Failure to Implement Dementia Care Plans Leads to Resident Altercation
Penalty
Summary
The facility failed to implement the dementia care plan for two residents, leading to a physical altercation. Resident 75, who had a history of aggression and resident-to-resident altercations, was not placed in a room close to the nursing station for close monitoring, as required by their care plan. This oversight allowed Resident 75 to approach Resident 20's bedside, resulting in a physical altercation where Resident 75 sustained scratches on the face. Resident 20, who had a history of aggression since June 2023, was involved in the altercation with Resident 75. The care plan for Resident 20 included interventions to prevent agitation and protect the safety of others, but these were not implemented effectively. As a result, Resident 20 was able to scratch Resident 75 during the altercation. Additionally, Resident 75 did not receive all scheduled doses of Memantine, a medication for dementia, with three doses missed in November 2024. This failure to administer medication as ordered could have contributed to the resident's aggressive behavior. The facility's policy on dementia care emphasizes the need for personalized care plans and consistent medication administration, which were not adhered to in this case.
Failure to Follow Pharmacy Recommendation for Hemoglobin A1C Test
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation for a resident was followed through with the medical doctor. The resident, who was admitted with diagnoses including end-stage renal disease on dialysis and type 2 diabetes mellitus, had a Hemoglobin A1C test result of 8.6%, which is above the normal range. Despite the pharmacy consultant's recommendation to repeat the Hemoglobin A1C test, the order was not executed, and the results were not communicated to the medical doctor. Interviews and record reviews revealed that the Registered Nurse Supervisor acknowledged the oversight, stating that the pharmacy consultant's recommendation was not acted upon, and the results were not relayed to the medical doctor. The Director of Nursing also confirmed awareness of the pharmacy's recommendation and admitted that not following through was an oversight. The facility's policy requires that the ordering practitioner be notified of results outside of normal ranges, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, Resident 20 and Resident 75, from abuse, resulting in a physical altercation. Resident 75, who had a history of aggressive behavior, was not monitored closely as required by their care plan, which specified that they should be kept near the nursing station. This lack of supervision allowed Resident 75 to approach Resident 20, who also had a history of aggressive behavior, leading to a confrontation in Resident 20's room. Resident 20 was admitted with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and dementia, and had severely impaired cognitive skills. Their Minimum Data Set (MDS) indicated physical and verbal aggression towards others. Resident 75, admitted with dementia, major depressive disorder, generalized anxiety disorder, and a psychotic disorder, had intact cognitive skills but required supervision and assistance with daily activities. Despite the care plan intervention to monitor Resident 75 closely, they were not placed near the nursing station, which contributed to the incident. The altercation occurred when Resident 75, after hearing Resident 20 use a derogatory term, approached Resident 20's bedside, resulting in Resident 75 being scratched. The facility's policy on abuse prevention emphasizes zero tolerance for abuse and the need to protect residents from such incidents. However, the failure to implement the care plan intervention for Resident 75 led to the altercation, highlighting a deficiency in the facility's ability to prevent resident-to-resident abuse.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident after hospitalization, violating the bed-hold policy. The resident, who had Parkinson's disease and intact cognition, was transferred to a General Acute Care Hospital (GACH) due to combative behavior and possession of drug paraphernalia. Despite being cleared by the GACH for return, the facility did not readmit the resident, resulting in the resident remaining at the hospital for two additional days. The facility's census indicated the resident's room was marked as empty, and the bed was given away, despite the resident's request for a bed hold. The facility's Director of Nursing (DON) communicated to the GACH that the resident required a substance abuse program, suggesting the facility could not meet the resident's needs. The GACH's social worker reported that the facility believed the resident was being taken to jail and no longer had a bed available. The facility's policy stated that a bed would be held for up to seven days if the resident or their representative requested it within 24 hours of transfer, which was not honored in this case.
Neglect of Resident Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident was free from neglect when a Certified Nurse Assistant (CNA) left the resident with soiled incontinence briefs for over two hours. The resident, who was admitted with diagnoses including cancer of the intestines, gait abnormalities, and osteoporosis, was dependent on substantial assistance for personal hygiene. The resident's care plan required checks for incontinence every two hours. On the day of the incident, the resident informed CNA 1 at noon that she was wet and needed to be cleaned, but CNA 1 delayed the care, stating that lunch trays were being served and promised to clean the resident after lunch. Despite the lunch trays being picked up by 1:30 p.m., CNA 1 was observed sitting at the nurse's station and did not attend to the resident. The resident remained in soiled briefs until at least 2:10 p.m., when CNA 1 was seen assisting another resident. Interviews with other staff members, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that the facility had a buddy system and team leaders available to assist if a CNA was too busy. The facility's policy required perineal care to prevent skin breakdown and maintain hygiene, which was not adhered to in this instance, leading to the resident feeling neglected and potentially at risk for skin issues.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that one of the sampled residents had a medical diagnosis indicated for the use of Depakote, a medication used to treat mental illness. The resident was admitted with diagnoses including major depressive disorder, dementia, and psychosis, but there was no specific medical diagnosis justifying the use of Depakote. This oversight was confirmed by the Registered Nurse Supervisor, who acknowledged that the absence of a medical diagnosis could lead to the unnecessary administration of the medication. Additionally, the facility did not adequately manage PRN psychotropic medications for another resident. The PRN orders lacked a specified duration, non-pharmacological interventions prior to use, monitoring for side effects and adverse reactions, and monitoring for hours of sleep. Furthermore, the PRN order for Xanax did not indicate a frequency, and other medications were ordered without a specified duration. These deficiencies were confirmed by the Director of Nursing, who emphasized the importance of informed consent and proper documentation to prevent unnecessary medication use. Both residents involved did not have informed consent documented for their psychotropic medications, which is a critical step to ensure that residents or their responsible parties are aware of the risks and benefits of the medications. The facility's policies and procedures require informed consent, a medical diagnosis for psychotropic medication orders, and thorough monitoring of psychotropic drug use, including the evaluation of non-pharmacological approaches before administering PRN medications. The failure to adhere to these policies resulted in the potential for unnecessary medication administration to the residents.
Delayed Administration of Prescribed Medications
Penalty
Summary
The facility failed to ensure that medications prescribed to a resident following dermatology visits were administered as ordered. The resident, who was admitted with cellulitis of the lower limbs, was prescribed several medications, including Ciprofloxacin, Mupirocin, Triamcinolone, Hibiclens, and Ammonium Lactate, to treat stasis dermatitis. These medications were delivered to the facility on the same dates they were prescribed, but there was a delay in their administration. Ciprofloxacin was administered six days after delivery, and Ammonium Lactate was applied five days after it was prescribed. Interviews with facility staff revealed a lack of communication and verification processes regarding medication orders and deliveries. Licensed Vocational Nurses and the Registered Nurse Supervisor acknowledged that medications were not administered promptly due to unawareness of the orders and failure to verify them against the delivery. The Director of Nursing admitted there was no system in place to ensure medications were checked against physician orders upon delivery. This deficiency resulted in delayed treatment for the resident's skin condition.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and monitor a resident who lacked decision-making capacity, resulting in the resident eloping from the facility. The resident, who had been diagnosed with bipolar disorder and schizoaffective disorder, was last seen in his room at approximately 6:54 p.m. on 10/10/2024. The resident was reported missing at 7:57 p.m., and despite a search by facility staff, he was not found until the following day when his responsible party informed the facility of his whereabouts. The resident was missing for approximately 14 hours. Interviews and record reviews revealed lapses in supervision and monitoring. The facility's receptionist, who was responsible for monitoring the front entrance, took breaks without ensuring coverage, and the front entrance alarm was not activated until after the resident had already left. The facility's policy on wandering and elopement was not effectively implemented, as the resident was able to leave unnoticed. The facility's assessment tool indicated a need for sufficient staff with appropriate competencies to ensure resident safety, which was not met in this instance.
Unauthorized Medical Procedure on Discharged Resident
Penalty
Summary
The facility failed to ensure that a resident, who had been discharged against medical advice, did not undergo a medical procedure at the facility without being under the care of a physician. The resident, who had a gastrostomy tube due to dysphagia, was discharged from the facility and was no longer under the care of a physician there. Despite this, the resident returned to the facility with their responsible party to have the gastrostomy tube removed in the Director of Nursing's office by a physician assistant. This procedure was performed without any orders or instructions for care, as the resident was no longer admitted to the facility. The resident's medical records indicated that they had been admitted with a diagnosis of dysphagia and had a gastrostomy tube placed. The resident was found to have intact cognition and required moderate assistance with activities of daily living. After being discharged against medical advice, the resident's responsible party expressed concerns about the gastrostomy tube while the resident was out on the street, leading to the decision to have the tube removed at the facility. This action was taken despite the facility's policy that residents should only be admitted upon the order of an attending physician, highlighting a failure to adhere to established procedures.
Missing Dermatology Consultation Notes
Penalty
Summary
The facility failed to ensure that the consultation notes from an external dermatology visit were readily available in the medical record for a resident. This deficiency was identified during a review of the resident's clinical records, which showed no documentation of the dermatology consultation note. The resident, who was admitted with cellulitis of the lower limbs, had a dermatology appointment scheduled, and upon returning from the appointment, there were no new orders documented in the progress notes. Interviews with facility staff revealed that the Licensed Vocational Nurse did not follow up with the physician's office to confirm or obtain the consultation notes after the resident's return. The Director of Nursing confirmed the absence of the consultation notes and acknowledged the risk of missed treatment and medications if staff did not follow up to obtain necessary documentation. The facility's policy requires that records be maintained in a form that is legible and readily available, which was not adhered to in this case.
Failure to Implement Timely Infection Control for C-Auris
Penalty
Summary
The facility failed to initiate a Change of Condition (COC) form and obtain physician's orders for infection prevention measures for a resident who tested positive for Candida Auris (C-Auris), a multidrug-resistant fungal infection. The resident was readmitted to the facility with a history of candidiasis, MRSA, and ESBL resistance. On the evening of 7/15/2024, the facility was informed by a General Acute Care Hospital (GACH) that the resident had tested positive for C-Auris. However, the Director of Nursing (DON) decided to follow up with the hospital the next day, delaying the implementation of necessary infection control measures. The Infection Prevention Nurse (IPN) acknowledged that the resident should have been placed on Enhanced Barrier Precautions (EBP) immediately upon notification of the positive C-Auris test to prevent transmission. Despite being informed on 7/15/2024, the COC was not initiated until the following day, 7/16/2024, which delayed the application of infection prevention precautions. The IPN and Registered Nurse Supervisor (RNS) both confirmed that the COC should have been started immediately upon receiving the test results. The facility's policy and procedure for Resident Isolation and Change of Condition Notification require immediate action when a resident is known or suspected to be infected with transmissible microorganisms. The delay in initiating the COC and implementing infection control measures placed other residents and staff at risk of infection. The DON later acknowledged the importance of placing a PPE cart by the resident's room and ensuring staff wore gowns when providing care to prevent the spread of infection.
Facility Fails to Maintain Safe and Homelike Shower Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents due to the presence of eight missing shower tiles and two cracked tiles in one of the two shower rooms. During an observation, five missing tiles were noted on the right side of the floor and three along the wall in the second shower stall, with two cracked tiles on the wall separating the first and second stalls. The Maintenance Supervisor acknowledged that the tiles had been in this condition for the past six months and expressed concern about the potential for resident injury. The Administrator also recognized the risk posed by the broken and missing tiles, acknowledging that they could lead to accidents and exposure to germs. The facility's policy, dated October 2023, mandates that the environment should be safe, clean, comfortable, and homelike, ensuring that the physical layout does not pose a safety risk. However, the current state of the shower room contradicts this policy, as it fails to provide a safe and homelike environment for the residents.
Failure to Conduct IDT Meetings for Residents Going Out on Pass
Penalty
Summary
The facility failed to implement its policy to conduct Interdisciplinary Team Meetings (IDT) for four residents who had physician orders to go out on pass for therapeutic purposes. This deficiency violated the residents' rights to participate in the development of their person-centered care plans. The residents involved had various diagnoses, including major depressive disorder, abnormalities of gait and mobility, dementia, and HIV, but all had intact cognition and the capacity to make decisions. Despite this, there was no documentation of IDT meetings to assess their ability to participate in activities outside the facility, as required by the facility's policy. During an interview, the Director of Nursing (DON) admitted to being unaware of the policy requiring IDT meetings before residents go out on pass. The facility's policy, dated 10/01/2023, mandates that the IDT assess the resident's decision-making capacity, physical disabilities, and ability to take medications independently before allowing them to go out on pass. The lack of IDT meetings meant that the residents and their representatives were not adequately informed or assessed regarding the process of going out on pass, which is crucial for ensuring their safety and understanding of the necessary procedures.
Failure to Administer Postoperative Eye Medications
Penalty
Summary
The facility failed to contact and inform the physician to clarify postoperative orders for a resident who returned from cataract surgery. This resulted in the resident not receiving prescribed eye medications, including Cyclogyl Ophthalmic solution, Phenylephrine HCL Ophthalmic solution, and Tropicamide Ophthalmic solution, for four days following the procedure. The resident, who had intact cognitive skills and required assistance with daily activities, was admitted with a diagnosis of type 2 diabetes mellitus. The deficiency was identified through interviews and record reviews, revealing that the resident returned with eye drops and verbal instructions to apply them every four hours, but no written orders were received. Despite attempts by a registered nurse to contact the physician, the orders were not clarified, and the medications were not administered until four days later. The Director of Nursing acknowledged that the staff should have immediately followed up with the physician to ensure the resident received the necessary postoperative medications.
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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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