Studio City Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Studio City, California.
- Location
- 11429 Ventura Blvd, Studio City, California 91604
- CMS Provider Number
- 555686
- Inspections on file
- 60
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Studio City Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, cerebral infarction, and severe cognitive impairment experienced changes in condition, including confusion, altered gaze, left-sided weakness, and facial twitching. A COC assessment initially included vital sign values, but later documentation only stated that vital signs were within normal limits without recording actual values, and 15-minute monitoring with vital signs reported by an RN was not charted. The DON confirmed there was no documented evidence of vital signs after the second noted change in condition, contrary to the facility’s charting policy requiring complete and accurate documentation of services and condition changes.
A resident with pneumonia and other comorbidities had an order for amoxicillin-clavulanate to be given twice daily for seven days. On one morning, the resident would not eat or open their mouth, and the assigned LVN did not administer the ordered medications, including the antibiotic, but documented on the MAR that seven medications were given. The LVN did not correct the MAR entry or document the refusal, and did not promptly notify the supervisor or MD of the missed antibiotic dose. The DON later confirmed that this constituted inaccurate documentation and that facility policy requires accurate charting of refusals and same-day MD notification for refused antibiotics.
A resident with multiple diagnoses, including pneumonia, had physician orders for several medications, among them an oral antibiotic. On a morning when the resident would not eat and would not open their mouth, an LVN did not administer seven ordered medications but nonetheless signed them as given on the MAR, including the antibiotic. The LVN did not document that the medications were not given, did not correct the erroneous MAR entries, and did not record a refusal or reason. The LVN also failed to notify the MD at the time of the missed antibiotic dose and only informed a supervisor several hours later. The DON confirmed this resulted in inaccurate documentation and was inconsistent with facility policies requiring complete, accurate charting and same-day MD notification for antibiotic refusal.
A resident's medical record did not accurately reflect a history of scabies, despite hospital discharge documentation and facility surveillance data indicating the diagnosis and ongoing treatment. The DON confirmed that the diagnosis section should have included this information to ensure complete and accurate records, as required by facility policy.
Three residents who were exposed to scabies and received physician-ordered prophylactic treatment did not have individualized care plans developed to address their exposure, treatment, or monitoring. Despite documentation of treatment administration, the DON confirmed that care plans were not created as required by facility policy, resulting in a lack of documented guidance for staff regarding scabies management.
Two residents did not receive medications according to physician orders: one was given oxycodone for pain levels below the ordered threshold, and another received diltiazem despite a systolic blood pressure below the hold parameter. The DON confirmed that nursing staff did not follow orders or facility policy regarding medication administration.
Three residents with various chronic conditions and cognitive impairments received Elimite cream for scabies prophylaxis without a diagnosis or testing, following a single confirmed case in another resident. Nursing staff and the DON confirmed that the medication was given as a precaution, despite facility policy requiring confirmation of suspected cases and no evidence of an outbreak.
The facility did not place a resident on contact isolation after a physician ordered a skin scraping to rule out scabies, and failed to ensure timely skin monitoring and documentation for three residents as ordered by a physician. Staff confirmed that contact precautions and documentation were not initiated as required by facility policy.
A resident with severe cognitive impairment and total dependence for ADLs was found with a blanket tied around the lower body and secured to a wheelchair, effectively restraining movement. Although there was a physician order for a self-release seat belt, there was no order or consent for the use of the blanket as a restraint. Staff and nursing leadership confirmed the blanket was not a self-release device and its use as a restraint was not authorized or in accordance with facility policy.
A resident with multiple risk factors for pressure ulcers was found to have excessive layers of linen and padding placed between them and a low air loss mattress (LALM), contrary to both manufacturer instructions and facility policy. Staff interviews revealed inconsistent knowledge of proper procedures, with some staff using up to eight layers instead of the required two, potentially compromising the effectiveness of the LALM in preventing pressure ulcers.
A resident with multiple health issues experienced a change in condition and was found on a floor mat. Although an immediate X-ray was ordered, it was not performed promptly, and the Attending Physician was not notified of the delay until the next morning, contrary to the facility's policy requiring prompt notification.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including dementia. A Change of Condition record inaccurately documented the notification time of the Responsible Party. Interviews with staff revealed discrepancies in the documentation, which did not align with the facility's policy on accurate record-keeping.
The facility failed to maintain a safe and homelike environment for residents by not keeping temperatures within the required range and not ensuring clean shower rooms. Observations showed temperatures below the required minimum and unsanitary conditions in shower rooms, including feces on a shower chair and unattended items. Staff acknowledged these issues, and the facility's policy emphasized the importance of a clean and comfortable environment, which was not upheld.
A resident with severely impaired cognition was physically abused by another resident with a history of altered behavior patterns. The incident occurred when one resident punched the other in the face, resulting in swelling and discoloration. Despite existing care plans and policies, the facility failed to prevent this incident, highlighting a deficiency in monitoring and protecting residents from abuse.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and high fall risks. Despite care plans and policies emphasizing the need for accessible call lights, observations revealed that call lights were often placed out of reach, preventing residents from calling for assistance. Staff interviews confirmed the oversight and acknowledged the potential risks associated with this deficiency.
The facility failed to ensure residents were free from physical restraints without proper documentation, affecting multiple residents. A resident was found with mitten restraints without a physician's order or consent. Two residents had their beds placed against the wall, considered a restraint, without necessary assessments. Another resident had all side rails up, and one had pillows restricting movement, both without proper documentation. Staff confirmed the lack of required orders and consents, emphasizing the importance of these measures for safety and resident rights.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Beds were used as restraints without care plans, urinary catheters lacked documentation, and a resident with PTSD had no care plan. Additionally, a resident on Melatonin was not monitored for sleep effectiveness, risking unnecessary medication use.
The facility failed to rotate injection sites for insulin and enoxaparin for several residents, as required by professional standards and facility policy. This deficiency was identified through a review of medication administration records and confirmed by nursing staff interviews, highlighting repeated use of the same injection sites over several months.
Two residents in a facility were not provided with proper pressure ulcer care due to issues with their low air loss mattresses (LALM). One resident's LALM was not powered on, while another's was set incorrectly according to their weight. These deficiencies were identified during observations and interviews, highlighting a failure to adhere to professional standards of practice in preventing pressure injuries.
Three residents with limited ROM did not receive appropriate treatments as ordered, including splints and exercises, due to inadequate documentation and communication by the RNA staff. This failure prevented necessary assessments and interventions by nursing and rehabilitation staff.
The facility failed to maintain a safe environment for residents, with deficiencies including improper placement of an oxygen concentrator on a fall mat, a bed not kept in the lowest position, a tab alarm cord posing entanglement risks, and unauthorized medications left at a resident's bedside. These actions increased the risk of falls and injuries, contrary to the facility's policies and procedures.
The facility failed to provide appropriate care for residents with urinary incontinence, leading to deficiencies in catheter management for three residents. A resident's catheter was removed without a physician's order, and sterile technique was not used during reinsertion. Additionally, urine output was not documented, resulting in hospitalization. Two other residents' catheters were not secured with anchors, increasing the risk of trauma and infection.
The facility failed to account for five doses of controlled medications for five residents and did not properly document and dispose of an expired Ativan vial. LVN 3 admitted to administering the medications but forgot to sign the accountability logs, while RN 4 disposed of the Ativan vial without the required presence of the DON and CP. These actions violated the facility's policies for handling controlled medications.
A resident in an LTC facility experienced medication administration errors, resulting in a 6.45% error rate. The resident did not receive docusate as ordered and received metformin at a different time than prescribed. The errors were acknowledged by an LVN and confirmed by the DON, highlighting a failure to adhere to the facility's medication administration policies.
The facility failed to rotate injection sites for insulin and enoxaparin for several residents, including those with diabetes and other conditions, leading to significant medication errors. Despite clear guidelines and physician orders, nursing staff repeatedly administered injections in the same sites, increasing the risk of adverse skin conditions. Interviews with staff confirmed the oversight, acknowledging it as a medication error.
The facility failed to manage and discard expired medications, including lorazepam and Aplisol vials, as per manufacturer's requirements and facility policies. Surveyors found expired and improperly labeled vials in medication rooms, which staff acknowledged could lead to ineffective treatment or infections. The facility's policies require proper labeling and disposal of expired medications, which was not followed, increasing the risk of harm to residents.
A facility failed to prepare and serve food that conserved flavor, appearance, and temperature, affecting residents' dietary intake. A resident with malnutrition was served unappetizing meals, leading to poor food consumption. Observations revealed mushy vegetables, soggy peach crisp, and improperly chilled salad served to 20 residents. The facility's policies on food preparation were not followed, impacting residents' appetites and nutritional intake.
The facility failed to accommodate the food preferences of two residents, leading to deficiencies in nutritional care. One resident was not offered a substitute after expressing dislike for the meat served, despite a care plan directive. Another resident, who disliked pasta, was served soup containing pasta, contrary to documented preferences. Staff did not adhere to policies ensuring resident choices are respected, impacting nutritional needs.
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed in the kitchen. The absence of separate thermometers in refrigeration units, the presence of dented cans in the wrong storage area, and dust buildup on equipment like the fire sprinkler and kitchen hood were noted. Additionally, the mixer and pans had food residue, indicating inadequate cleaning. These deficiencies could lead to harmful bacteria growth and cross-contamination, affecting residents receiving food from the kitchen.
The facility lacked a comprehensive policy for the storage of food brought by family and visitors, stating it cannot store outside food. Staff interviews revealed inconsistencies in handling and storage, with no refrigeration available in certain areas. This posed a risk of food spoilage and potential foodborne illness, affecting 117 residents who could experience decreased food intake and psychosocial harm.
A Certified Occupational Therapy Assistant (COTA) at the facility continued to perform occupational therapy treatments for at least three months after their California license expired. The Director of Rehabilitation confirmed the license expiration, and the facility had not received any written confirmation from the California Board of Occupational Therapy allowing the COTA to continue practicing. Despite this, the COTA was still scheduled to work, contrary to the facility's policy requiring active licenses for all occupational therapists.
The facility failed to maintain accurate clinical records for several residents, leading to discrepancies in meal intake documentation and restorative nursing care. A CNA inaccurately recorded a resident's meal consumption, while RNAs failed to document the correct use and tolerance of splints and exercises for other residents. These errors could impact the assessment and care planning for the residents involved.
The facility failed to maintain an effective infection prevention and control program, with issues such as medical equipment touching the floor, improper PPE use by staff, inadequate PPE supplies, and improper linen storage. Additionally, water temperatures were below recommended levels, risking Legionella growth.
Two residents with severely impaired cognition were given Fibersource HN instead of the prescribed Jevity 1.2 due to a stock issue. The substitution was made without a physician's order, as required by facility policy, placing the residents at risk for complications. The nursing staff failed to notify the physician or obtain an order for the formula change.
A facility failed to administer IV fluids according to professional standards for a resident with an IV catheter. The PIV dressing lacked the insertion date and nurse's initials, and no sterile injection cap was placed over the injection port. The resident, with chronic respiratory failure and severely impaired cognition, was at risk for complications. Observations confirmed these deficiencies, contrary to the facility's policy requiring proper documentation and sterile procedures.
Two residents with tracheostomies did not receive proper care as the facility failed to place a fenestrated gauze under the tracheostomy flange, contrary to professional standards and facility policy. This oversight was observed by respiratory therapists and acknowledged by the DON, highlighting a deficiency in the care provided.
A facility failed to address a Consultant Pharmacist's recommendation for a Medication Regimen Review for a resident prescribed pantoprazole for GERD. The recommendation to re-evaluate the medication due to potential long-term side effects was not reviewed or documented by a physician within the required timeframe, as confirmed by interviews with facility staff.
A resident with depression and cognitive impairments was prescribed Melatonin to regulate circadian rhythm, but the facility failed to monitor sleep hours or assess the medication's effectiveness and side effects. Despite recommendations from the Consultant Pharmacist, the facility did not update the indication for Melatonin use or document sleep monitoring, leading to potential unnecessary medication use.
A resident with type two diabetes and heart failure received his lunch tray after the scheduled meal time, contrary to the facility's policy. The resident reported receiving meals at 1:00 p.m., while the policy stated lunch should be served between 12:00 p.m. and 12:45 p.m. The DON confirmed the delay, which could affect food temperature and resident wellbeing.
A resident in an LTC facility, admitted with type two diabetes and heart failure, reported ants in his room, causing discomfort and concern about food contamination. The Maintenance Supervisor confirmed the ant presence, despite a recent visit from the contracted pest control service. The facility's pest control policy was not effectively implemented, as ants were observed in the resident's room, indicating a lapse in maintaining a pest-free environment.
A facility failed to accurately code the MDS assessments for a resident with PTSD, omitting the diagnosis in assessments despite its presence in the resident's records. This was confirmed by the MDS Coordinator and acknowledged by the DON, highlighting a lapse in accurately reflecting the resident's health status.
A facility failed to comply with regulations by accommodating five residents in a room designed for a maximum of four. Room [ROOM NUMBER] had five beds and sufficient space for necessary care, with no reported issues from residents or staff. The facility had submitted a waiver and requested a continued waiver for this arrangement.
The facility failed to meet federal regulations for room size, providing less than the required 80 square feet per resident in three rooms. Despite this, no concerns were raised by residents or staff, and a waiver request was submitted, arguing no adverse effects on residents' health and safety.
A facility failed to obtain informed consent before applying a self-release seat belt, considered a restraint, to a resident with muscle weakness and diabetes. The resident was agitated and at risk of falling, prompting staff to apply the restraint without notifying the family. The restraint was removed after the family objected, highlighting a violation of the resident's rights to be informed and participate in treatment decisions.
A resident with a high fall risk was improperly restrained with a self-release seat belt without obtaining informed consent from their representative. The restraint was applied after the resident exhibited agitation and an unsteady gait, but the family was not informed prior to its use. The restraint was later removed after the family refused its use, highlighting a violation of the resident's rights and facility policies.
A facility failed to create a care plan for a resident's use of a self-release seat belt, which was considered a restraint since the resident could not unbuckle it independently. Despite a physician's order for the belt due to the resident's unsteady gait and frequent falls, the facility did not adhere to its policy requiring a care plan for restraint use, potentially affecting the resident's wellbeing and freedom of movement.
A resident with a tracheostomy experienced a partial displacement of their tracheal tube, which was replaced with a smaller tube by a respiratory therapist. Despite diminished breath sounds and minimal airflow, the RN did not notify the physician as required. The resident later experienced breathing difficulties and was pronounced dead after paramedics arrived. The facility failed to follow its policy for notifying a physician of a significant change of condition.
A resident with a tracheostomy experienced a partial tube displacement, leading to respiratory distress. Despite intervention by a respiratory therapist, the resident's condition worsened, and staff failed to notify the physician or take appropriate actions. The resident was found with breathing difficulties and was pronounced dead upon paramedics' arrival.
A resident with a tracheostomy experienced a change of condition when their tracheal tube was displaced and replaced with a smaller size, leading to diminished breath sounds. The RN failed to notify the MD or secure an x-ray order, and delayed calling emergency services when the resident showed signs of distress. The resident was later found deceased by paramedics, highlighting a failure to follow facility protocols for change of condition and emergency response.
The facility failed to post accurate daily staffing information in the sub-acute unit, displaying data for the following day instead of the current date. This was confirmed by the Infection Preventionist and the DON, who noted that the Director of Staff Development had posted the next day's information before leaving. The facility's policy requires daily posting of staffing data for each shift, including the current date, to ensure awareness of available staff for resident care.
Failure to Document Vital Signs During Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting vital signs during a change of condition. The resident was admitted with metabolic encephalopathy, cerebral infarction, and unspecified dementia, and had severely impaired cognitive skills for daily decision making per the MDS dated 2/14/2026. On 2/26/2026 at 10:30 a.m., a Change of Condition (COC) Assessment Form documented that the resident was confused, unable to make eye contact, and staring to the right side, with vital sign values recorded in the Background section of the form. Later, at 12 p.m., the resident was observed with increased weakness on the left side of the body and facial twitching, and the COC Assessment Form stated that the resident’s vital signs were within normal range, but no actual vital sign values were documented to support this. During a telephone interview, RN 1 stated that licensed nurses were monitoring the resident every 15 minutes, including vital signs, but acknowledged that she did not document this monitoring in the resident’s medical record and that she should have documented the resident’s COC progress or decline. In a subsequent interview and concurrent record review with the DON, the DON confirmed there was no documented evidence of the resident’s vital signs after the second COC at 12 p.m. on 2/26/2026 and stated that failure to document vital signs after a COC could result in miscommunication among the healthcare team. The facility’s Charting and Documentation policy, last reviewed on 4/16/2025, required that all services provided and any changes in the resident’s condition be documented in an objective, complete, and accurate manner, which was not followed in this case.
Failure to Accurately Document and Administer Ordered Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident was admitted with diagnoses including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder. A physician’s order dated 1/19/2026 directed that amoxicillin-potassium clavulanate 875 mg-125 mg be given by mouth every 12 hours for seven days for a bacterial infection, and the care plan initiated the same day identified this medication for treatment of pneumonia with an intervention to administer medications as ordered and assess for complications. On 1/20/2026, the MAR showed that the resident was documented as having received the ordered amoxicillin-potassium clavulanate at 9 a.m. However, during interview and concurrent record review, the LVN assigned to the resident that day stated that the resident was not eating breakfast and would not open his mouth, so the morning medications, including the antibiotic, were not actually given. The LVN acknowledged that she signed off seven medications on the MAR as given even though they were not administered and did not enter any note indicating that the medications were signed off in error. She further stated that she should have documented the error and notified her supervisor and the physician when the resident refused the antibiotic. The DON confirmed during interview and record review that if a resident refuses or is unable to take medications, the nurse should not sign them as given but should document the refusal and the reason, and that the MD must be notified within the shift of a missed or refused antibiotic. The DON stated that the documentation on the MAR was inaccurate because the medications were not given and that the MD was not notified of the missed antibiotic, although the MD was notified of the resident’s lethargy as a change of condition. Review of facility policies showed that charting must be objective, complete, and accurate, and that medication refusal must be documented with physician notification the same day for antibiotics, which did not occur in this case.
Inaccurate MAR Documentation and Failure to Document Antibiotic Refusal
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident in accordance with professional standards. The resident was admitted with multiple diagnoses, including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder, and had physician orders for several medications, including sertraline, Colace, cranberry tablets, memantine, Liquacel, acetaminophen, and later amoxicillin-potassium clavulanate for pneumonia. The facility’s policies required that documentation in the medical record be objective, complete, and accurate, and that medication refusals be documented with physician notification, particularly for antibiotics. On the date in question, the Medication Administration Record (MAR) showed that the resident received seven ordered medications, including the antibiotic amoxicillin-potassium clavulanate, at a morning administration time. However, the assigned LVN reported that the resident was not eating breakfast and would not open his mouth, and therefore the morning medications were not actually given. Despite this, the LVN signed off all seven medications on the MAR as if they had been administered and did not enter any note indicating that the medications were signed off in error or that they were refused or not taken. During interviews, the LVN acknowledged that the medications were not given, that she had signed them as administered by accident, and that she did not complete the required corrections on the MAR to indicate wrong documentation. She also stated she did not notify the physician at the time the antibiotic was refused and only informed her supervisor several hours later when the resident also refused lunch. The DON confirmed that if a resident refuses or is unable to take medications, the nurse should not sign them as given, should document the refusal and the reason, and should notify the MD within the shift for missed or refused antibiotics. The DON characterized the MAR entries as inaccurate documentation and noted that the facility’s policies required accurate charting and same-day physician notification for refusal of antibiotics.
Failure to Accurately Document Resident Diagnosis in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident by not documenting the resident's history of scabies in the diagnosis section of the medical record. The resident was admitted and readmitted with multiple diagnoses, including dementia, type 2 diabetes mellitus, and chronic kidney disease. Upon review, the resident's discharge summary from a general acute care hospital indicated a diagnosis of scabies, with instructions to continue ivermectin treatment and maintain isolation. Surveillance data collected at the facility also noted the resident's scabies diagnosis and ongoing treatment. Despite this, the resident's official diagnosis list in the facility's records did not include a history of scabies. During interviews, the DON acknowledged that the diagnosis should have reflected the resident's history of scabies, even if resolved, to provide an accurate synopsis of the resident's condition. The facility's policy required that documentation in the medical record be objective, complete, and accurate, but this standard was not met in this instance, resulting in inaccurate documentation for the resident.
Failure to Develop Care Plans for Scabies Exposure
Penalty
Summary
The facility failed to develop comprehensive care plans addressing potential exposure to scabies for three residents. Each resident had documented physician orders for prophylactic treatment with Elimite 5% cream following probable exposure to scabies, and the treatment was administered and recorded in the Treatment Administration Record. However, there was no evidence that individualized care plans were created to address the exposure, treatment, or monitoring for scabies for these residents. Resident 1 was admitted with multiple diagnoses, including diabetes mellitus, chronic pain syndrome, and COPD. The resident's cognitive status was reported as intact on the Minimum Data Set, and the resident required supervision for activities of daily living. Resident 2 had metabolic encephalopathy, generalized muscle weakness, and unspecified dementia, with severely impaired cognitive skills and total dependence on staff for daily activities. Resident 3 had atherosclerosis heart disease, unspecified chest pain, and cardiomegaly, with moderately impaired cognitive skills and a need for moderate assistance with some activities. All three residents received the prescribed prophylactic treatment for scabies exposure, as documented in their records. During an interview and record review with the Director of Nursing, it was confirmed that no care plans were developed for the residents' possible exposure to scabies. The facility's policy required the development of individualized nursing care plans to promote continuity of care, but this was not followed in these cases. The lack of care plans for scabies exposure and treatment was acknowledged by the Director of Nursing, who stated that this omission could result in nurses not following the appropriate plan of care for scabies treatment and prevention.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for two residents. For one resident with diagnoses including diabetes mellitus, low back pain, and COPD, the physician order specified that oxycodone 30 mg should be administered by mouth every six hours as needed for severe pain levels of seven to ten. However, the Medication Administration Record (MAR) showed that licensed nurses administered oxycodone when the resident's pain level was six on multiple occasions. The Director of Nursing (DON) confirmed that the nurses did not follow the physician's order and should have performed a proper pain assessment and contacted the physician for any necessary adjustments. For another resident with metabolic encephalopathy, secondary hypertension, and dementia, the physician order required diltiazem 60 mg to be given every six hours for high blood pressure, with instructions to hold the medication if the systolic blood pressure (SBP) was below 110. The MAR indicated that diltiazem was administered when the resident's SBP was 108/70. The DON acknowledged that the medication should have been held according to the physician's order to prevent further decrease in blood pressure. A review of the facility's policy and procedure for medication administration emphasized the importance of following the five rights of medication administration and adhering to physician orders, including taking vital signs immediately before administering medications when required. The DON confirmed that the facility's policy was to follow the physician's order, and the failures identified were not in accordance with this policy.
Unnecessary Administration of Scabies Prophylaxis
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary medications when Elimite cream, a treatment for scabies, was administered as prophylaxis despite the absence of a scabies diagnosis or outbreak. Resident 1, with a history of diabetes mellitus, chronic pain syndrome, and COPD, was admitted with intact cognitive skills and required supervision for daily activities. The resident received Elimite cream following a physician's order for asymptomatic prophylaxis after a roommate was diagnosed with scabies, despite not being tested or showing symptoms. Resident 2, diagnosed with metabolic encephalopathy, generalized muscle weakness, and unspecified dementia, was dependent on staff for all activities of daily living and also received Elimite cream as a preventive measure. Similarly, Resident 3, with a history of atherosclerosis, chest pain, and cardiomegaly, and moderate cognitive impairment, was given Elimite cream for the same reason. In all cases, the residents did not have a diagnosis of scabies, nor were they tested for the condition prior to administration of the medication. Interviews with nursing staff and the Infection Preventionist confirmed that Elimite was administered to these residents as a precaution after a single positive case of scabies was identified in another resident who had been readmitted from the hospital. The Director of Nursing acknowledged that the facility's policy required scraping and confirmation of suspected cases, and that a scabies outbreak is defined as two confirmed cases. The administration of Elimite in these circumstances was recognized as unnecessary, as there were no new suspected or confirmed cases among the treated residents.
Failure to Implement Infection Control Measures for Suspected Scabies
Penalty
Summary
The facility failed to implement appropriate infection control measures for three residents following a physician's order to rule out scabies. Specifically, after a physician ordered a skin scraping for one resident to test for scabies, the resident was not placed on contact isolation as required by facility policy. Observations confirmed that there was no contact isolation signage or personal protective equipment (PPE) available at the resident's door, and both the Infection Preventionist and Director of Nursing acknowledged that contact isolation should have been initiated when the order was given. Additionally, the facility did not ensure that skin monitoring was performed and documented for three residents after a physician ordered such monitoring. Review of the Treatment Administration Records (TAR) and progress notes revealed that skin monitoring was not started until two days after the physician's order, resulting in a gap in monitoring and documentation. Nursing staff confirmed that this delay occurred and acknowledged that it could lead to a delay in care. The facility's policies and procedures require the initiation of transmission-based precautions and timely documentation of infection surveillance data. However, these protocols were not followed in this instance, as evidenced by the lack of contact isolation and delayed skin monitoring for the affected residents. The failures were confirmed through interviews with staff and review of medical records and facility policies.
Unauthorized Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence for activities of daily living was found in a wheelchair with a white blanket wrapped around his lower abdomen to knees, with the edges secured to the wheelchair, effectively restraining him. The resident had a physician order and consent for a self-release seat belt, but there was no order or consent for the use of a blanket as a restraint. The facility's records indicated the resident lacked capacity to make decisions, and the Minimum Data Set confirmed severe impairment in daily decision-making. Observations revealed that the blanket was tied at the back of the wheelchair, and staff interviews confirmed that the blanket was not a self-release device and should not have been used in that manner. Both the LVN and CNAs interviewed stated that the resident could not have tied the blanket himself, and that staff should have checked to ensure no unnecessary restraints were applied. The Assistant Director of Nursing and Director of Nursing both acknowledged that the use of the blanket as a restraint was not authorized, and that the facility's policy for restraint use, which requires assessment, physician order, and monitoring, was not followed in this case. The facility's policy defined physical restraints as any device or material that the resident cannot remove easily and which restricts freedom of movement. The policy also outlined the need for assessment, physician order specifying the restraint, purpose, and monitoring, as well as informed consent. In this incident, these procedures were not followed, resulting in the unauthorized use of a physical restraint on the resident.
Failure to Follow LALM Protocols for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident who was at risk due to multiple medical conditions, including diabetes mellitus, heart failure, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Despite a physician order for a low air loss mattress (LALM) to manage and prevent pressure ulcers, staff placed multiple layers of linen and padding—totaling eight layers—between the resident and the LALM, contrary to both the manufacturer's instructions and facility policy, which specified no excessive padding should be used. Observations and interviews revealed inconsistent understanding among staff regarding the correct number of linen layers to use with the LALM. A CNA identified eight layers, while an RN believed four layers were appropriate, and the Infection Preventionist and DON both stated that only two layers, including the incontinence brief, should be present. Facility policy and the LALM operation manual both emphasized the importance of avoiding excessive padding to prevent interference with the mattress's pressure-relieving function. This failure to follow established protocols had the potential to contribute to the development or worsening of pressure ulcers for the resident.
Delayed Physician Notification for Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of the Attending Physician (AP) for a resident who experienced a change in condition. The resident, admitted with diagnoses including a urinary tract infection, osteoporosis with a vertebra fracture, and unspecified dementia, was found sitting on a floor mat. A Certified Nursing Assistant (CNA) informed a Licensed Vocational Nurse (LVN) about the situation, and the AP was notified, resulting in an immediate order for a left leg X-ray. However, the X-ray was not performed promptly, and the AP was not informed of this delay until the following morning. The facility's policy requires prompt notification of the physician upon a change in condition, but this was not adhered to, as the AP was not informed within the expected timeframe. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the staff should have notified the AP within two hours if the stat X-ray was not completed. The delay in communication resulted in a failure to obtain timely instructions from the physician for the resident's proper management.
Inaccurate Documentation of Resident's Change of Condition
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, which was identified during a survey. The resident was admitted with diagnoses including a urinary tract infection, age-related osteoporosis with a current pathological vertebra fracture, and unspecified dementia. A Change of Condition (COC) record indicated that the resident was found sitting on the floor mat, and the Responsible Party (RP) was notified. However, discrepancies were found in the documentation of the notification time. The COC incorrectly stated that the RP was notified on the same day at midnight, while it should have been documented as the following day. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the documentation was inaccurate, and the time of notification was not properly recorded in the COC and Progress Notes. The facility's policy and procedure on charting and documentation emphasized the importance of accurate and complete records to facilitate communication among the interdisciplinary team. The RN admitted to documenting the wrong date for the RP notification, which was confirmed during the review of the facility's policy and procedure.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents, as evidenced by the facility's inability to maintain temperatures within the required range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperatures in various rooms and areas of the facility were below the minimum required, with some areas as low as 60 degrees Fahrenheit. This failure was acknowledged by the Maintenance Assistant and Maintenance Supervisor, who confirmed that the facility's heating system was not functioning properly, particularly affecting certain rooms and areas. The Director of Nursing also confirmed that the facility's temperatures were not within the regulatory requirements, which could lead to discomfort for the residents. Additionally, the facility did not ensure that shower rooms were kept clean and sanitary. Observations in the shower rooms revealed unsanitary conditions, including towels and gloves on the floor, feces on a shower chair, and unattended disposable briefs and razors. Licensed Vocational Nurse 2 and the Maintenance Assistant both acknowledged these issues, stating that the equipment and rooms should be cleaned and disinfected after each use to prevent infection and maintain a homelike environment. The Director of Nursing confirmed that the facility staff failed to clean the equipment and shower rooms after resident care, which did not provide a clean and homelike environment for the residents. The residents involved in this deficiency had significant medical conditions and cognitive impairments, which made them dependent on the facility staff for their activities of daily living and unable to make decisions for themselves. The facility's policy and procedure on providing a homelike environment emphasized the importance of maintaining a clean, sanitary, and orderly environment with comfortable and safe temperatures. However, the facility's failure to adhere to these standards resulted in a deficiency that had the potential to impact the residents' comfort and well-being.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the face. The incident involved Resident 1, who had severely impaired cognition due to dementia and Alzheimer's disease, and Resident 2, who also had severely impaired cognition and a history of altered behavior patterns. On the day of the incident, Resident 1 was wheeling towards his bed when Resident 2, who was sitting on his own bed, stood up, grabbed Resident 1's call light, and punched Resident 1 in the face. This resulted in swelling and discoloration on Resident 1's face and eyes. The incident was witnessed by Resident 3, who immediately reported it to the nursing station. Upon assessment by the RN Supervisor, Resident 1 was found with facial swelling and discoloration, and was administered Tylenol for pain. Resident 2's plan of care had previously identified episodes of anger and inability to cope with stimuli, but the facility failed to prevent the physical aggression towards Resident 1. The facility's policies on monitoring residents with behavioral symptoms and preventing abuse were not effectively implemented, as evidenced by the incident. The staff, including direct caregivers and nursing supervisors, were responsible for monitoring residents with potential for conflict and anger, but the measures in place were insufficient to prevent the physical abuse of Resident 1 by Resident 2.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for several residents, which is a critical component of providing reasonable accommodation for resident needs and preferences. Resident 35, who was admitted with diagnoses including cerebral infarction and muscle weakness, was observed with the call light on the floor, out of reach. Despite the care plan indicating the need for the call light to be within easy reach, staff failed to notice and rectify this during their visits to the resident's room. Interviews with staff, including a CNA and LVN, confirmed the oversight and acknowledged the potential risk for falls when residents cannot access their call lights. Similarly, Resident 144, who had a history of traumatic subdural hemorrhage and severely impaired vision, was found with the call light placed on a bedside drawer, away from reach. The care plan for this resident also specified the need for the call light to be within easy reach due to the resident's high fall risk. Staff interviews revealed an understanding of the importance of call light accessibility, yet the deficiency persisted, indicating a lapse in adherence to the facility's policy. Residents 104 and 134, both with severe cognitive impairments and high fall risks, were also observed with call lights out of reach. Despite care plans and facility policies emphasizing the necessity of having call lights accessible, these residents were unable to call for assistance due to improper placement of the call lights. The DON confirmed that the pad call lights should be placed adjacent to the residents' bodies to ensure activation, highlighting a consistent failure across multiple cases to adhere to established protocols.
Failure to Obtain Proper Documentation for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, affecting several residents. For Resident 6, the facility did not obtain a physician's order, informed consent, or perform a restraint use assessment for the use of left-and-right hand mitten restraints. The resident, who was dependent on staff for activities of daily living and had a history of pulling out a gastrostomy tube, was observed with mitten restraints without the necessary documentation or assessments. Staff confirmed the lack of consent and order, acknowledging the importance of these measures to determine the necessity and safety of the restraints. For Residents 126 and 9, the facility placed their beds against the wall, which was considered a restraint, without obtaining a physician's order, informed consent, or performing an assessment. Both residents had cognitive impairments and were dependent on staff for daily activities. Staff confirmed the absence of necessary documentation and assessments, emphasizing the importance of informed consent and safety evaluations to respect the residents' rights and ensure their safety. Resident 467 was found with all four side rails up, considered a restraint, without a physician's order, informed consent, or assessment. The resident had a high fall risk and was dependent on staff for mobility and daily activities. Similarly, Resident 30 had pillows tucked under fitted sheets to prevent falling out of bed, which restricted movement and was considered a restraint. The facility failed to obtain the necessary documentation and assessments for these measures, highlighting a pattern of non-compliance with restraint use protocols.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident 9, the bed was placed against the wall, which was considered a restraint, yet there was no care plan addressing this. Similarly, Resident 126's bed was also placed against the wall without a care plan, and Resident 467 was observed with all four side rails up, also considered a restraint, without an accompanying care plan. These actions were not documented in care plans, which are essential for ensuring consistent and safe care. Resident 116 had a urinary catheter in place, but there was no care plan documenting its use, reasons for insertion, or interventions to mitigate potential adverse effects. Resident 30 was found with pillows tucked under the fitted sheet to prevent movement, which was considered a restraint, yet there was no care plan addressing this practice. Additionally, Resident 59 used a self-release seat belt in a wheelchair for positioning, but there was no care plan to guide staff on its use and ensure safety. Resident 111, diagnosed with PTSD, did not have a care plan addressing this condition, which is crucial for guiding staff in providing appropriate interventions. Furthermore, Resident 126 was prescribed Melatonin for sleep, but there was no monitoring of sleep hours to assess the medication's effectiveness, as outlined in the care plan. This lack of documentation and monitoring could lead to the use of unnecessary medications. The facility's failure to implement these care plans resulted in inconsistent care and potential harm to the residents.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and enoxaparin administration for several residents. This deficiency was identified for five residents who were receiving insulin and one resident who was receiving enoxaparin. The failure to rotate injection sites was observed through a review of medication administration records and confirmed during interviews with nursing staff. The facility's policy and procedure, as well as manufacturer guidelines, clearly indicated the necessity of rotating injection sites to prevent adverse skin conditions such as lipodystrophy and localized cutaneous amyloidosis. Resident 116, who was admitted with diagnoses including type 2 diabetes mellitus and acute kidney failure, had multiple instances where insulin was administered in the same area without rotation. Similarly, Resident 38, who was on anticoagulant therapy with enoxaparin, also had repeated injections in the same site. The records showed that the facility's staff did not follow the prescribed orders to rotate injection sites, which was confirmed by interviews with the Registered Nurse and the Director of Nursing. Other residents, including Residents 12, 56, 125, and 49, also experienced similar issues with insulin administration. The records indicated repeated use of the same injection sites over several months, contrary to the facility's policy and the manufacturer's guidelines. Interviews with nursing staff and the Director of Nursing further confirmed the failure to rotate injection sites, which could lead to skin abnormalities. The facility's policy and procedures, as well as the manufacturer's guidelines, were not followed, resulting in this deficiency.
Failure to Ensure Proper Use of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in their care. Resident 67, who was admitted with conditions such as hemiplegia, peripheral vascular disease, and venous thrombosis, was found to have a low air loss mattress (LALM) that was not powered on. This mattress is crucial for distributing the resident's body weight to prevent skin breakdown. Despite the resident's high risk for skin breakdown and the care plan's directive to ensure the LALM is inflated, the power was off during an observation. The Director of Nursing (DON) confirmed that the staff should have turned on the power to provide necessary therapy, and the failure to do so could lead to the development or worsening of pressure injuries. For Resident 469, who was admitted with respiratory failure and a stage 3 pressure ulcer, the LALM was not set according to the resident's weight. The resident's care plan included the use of pressure-relieving devices, and the resident was assessed as high risk for skin breakdown. However, the LALM was set at 160, while a sticker on the device incorrectly indicated it should be set at 200. The Treatment Nurse (TN) acknowledged that the setting should be based on the resident's weight, which was 136 pounds, and that the sticker could mislead staff into setting the LALM incorrectly. The DON stated that the staff should have clarified the correct setting with the attending physician to ensure appropriate therapy. These deficiencies highlight the facility's failure to adhere to professional standards of practice in preventing pressure injuries. The incorrect use and settings of the LALMs for both residents had the potential to contribute to the development or worsening of pressure ulcers, as confirmed by the observations and interviews with the facility's staff.
Failure to Provide Appropriate ROM Treatments
Penalty
Summary
The facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM) and mobility for three residents with limited ROM. Resident 6 was not consistently provided with a right knee splint during the Restorative Nursing Aide Program (RNA) as ordered. The RNA did not document or report when Resident 6 did not complete range of motion exercises or wear the right knee splint, despite the resident's resistance and inability to tolerate the splint several times a week. This lack of documentation and communication prevented necessary assessments and interventions by nursing and rehabilitation staff. Resident 125 was not provided with a left elbow splint and both hand rolls as ordered. The RNA responsible for Resident 125 assumed the resident no longer needed the splints and did not apply them, nor did they document or report this deviation from the care plan. The RNA documentation inaccurately reflected that the splints were applied daily, which was not the case. This failure to follow the RNA order and accurately document the resident's care prevented the facility from assessing the resident's condition and making necessary adjustments to the care plan. Resident 138 did not consistently receive the left elbow splint, left resting hand splint, and right hand roll as ordered. The RNA sometimes applied the splints for only 1-2 hours instead of the prescribed 4-6 hours, and this was not documented. Additionally, there was no documentation of whether the resident completed range of motion exercises or sat at the edge of the bed as part of the RNA program. The lack of accurate documentation and reporting hindered the facility's ability to assess the resident's progress and make informed decisions about their care.
Deficiencies in Accident Hazard Prevention and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for four residents. For one resident, an oxygen concentrator was improperly placed on top of a fall mat, compromising the mat's effectiveness and increasing the risk of injury from falls. The resident had a history of falls and was at high risk due to multiple health conditions, including dementia and a tracheostomy. The facility's policy emphasized the importance of maintaining a clutter-free environment, which was not adhered to in this case. Another resident's bed was not kept in the lowest position after care, contrary to the facility's policy and the manufacturer's guidelines. This oversight increased the risk of falls for the resident, who had impaired vision and was dependent on assistance for daily activities. The resident was part of a fall prevention program, yet the bed height was not managed appropriately, as observed by a CNA and confirmed by the DON. Additionally, a resident's tab alarm cord was too long, posing a risk of entanglement or choking. The alarm was not functioning correctly due to the cord's length, which failed to alert staff when the resident moved. The facility's policy required proper adjustment of such devices to ensure safety. Lastly, another resident had unauthorized medications at their bedside, which were not removed by staff despite the resident's inability to self-administer drugs safely. This oversight was against the facility's policy, which required medications to be administered only with a physician's order and proper assessment.
Deficiencies in Urinary Catheter Management
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary incontinence, specifically in the management of urinary catheters, which led to deficiencies in care for three residents. Resident 417's indwelling catheter was removed by Treatment Nurse 1 without a physician's order, and there was no documentation of the removal or monitoring for urinary retention. This action was taken based on the nurse's assumption that the resident did not need the catheter, despite the resident's history of urinary retention. The catheter was later reinserted by Registered Nurse 8 without using sterile technique, increasing the risk of infection. Additionally, the facility did not measure or document Resident 417's urine output between the removal and reinsertion of the catheter, which is crucial for monitoring the resident's condition. This lack of documentation and monitoring led to the resident being hospitalized for evaluation of decreased urinary output. The facility's policies and procedures, which require physician orders for catheter removal and the use of sterile techniques for catheter insertion, were not followed, contributing to the resident's decline and subsequent hospitalization. For Residents 158 and 150, the facility failed to secure their urinary catheters with an anchor or securement device, as required by facility policy. This oversight posed a risk of catheter dislodgement, which could lead to trauma and infection. The lack of securement devices was observed during interviews and inspections, and staff acknowledged the potential harm caused by unsecured catheters. These deficiencies highlight a failure to adhere to established protocols for catheter care, increasing the risk of complications for the residents involved.
Controlled Medication Accountability and Disposal Failures
Penalty
Summary
The facility failed to account for five doses of controlled medications for five residents in one of the inspected medication carts. This discrepancy was discovered during an observation of Medication Cart Station 1, where the count of medications in the bubble packs did not match the accountability log. Specifically, doses of hydrocodone with acetaminophen, lacosamide, Ativan, and viberzi were missing for Residents 30, 42, 60, 123, and 317. Licensed Vocational Nurse (LVN) 3 admitted to administering these medications but forgot to sign the accountability logs, failing to follow the facility's policy of documenting each dose immediately after administration. Additionally, the facility did not properly document and dispose of an expired Ativan vial for Resident 143. During an observation in the Medication Room Subacute, it was found that the accountability log lacked the date and signatures of the licensed staff involved in the disposal process. Registered Nurse (RN) 4 disposed of the Ativan vial without the presence of the Director of Nursing (DON) and the Consultant Pharmacist (CP), as required by the facility's policy. RN 4 acknowledged overlooking the controlled medication disposal policy, which compromised the accountability of the controlled medication. The facility's policies and procedures for handling controlled medications, including documentation, storage, and disposal, were not adhered to, leading to these deficiencies. The DON confirmed that the accountability logs should be signed and dated by the appropriate staff during disposal, and that LVN 3 failed to document the administration of controlled medications timely. These actions and inactions resulted in a lack of control and accountability for controlled medications, increasing the risk of diversion and potential harm to residents.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.45% error rate during a medication administration observation. This deficiency involved a resident who did not receive docusate as ordered and received metformin at a different time than prescribed. The errors were identified during an observation where an LVN administered metformin to the resident outside the prescribed time frame and omitted the administration of docusate. The LVN acknowledged these errors and the potential risks associated with them, including stomach irritation and constipation. The resident involved had a medical history of Diabetes Mellitus 2 and gastritis, and was prescribed docusate for bowel management and metformin for diabetes management. The facility's policy required medications to be administered within a 60-minute window of the prescribed time, which was not adhered to in this case. The facility's policy also emphasized the importance of following prescriber orders and verifying medication details before administration. The Director of Nursing confirmed the errors and the potential risks to the resident's health due to the deviation from the prescribed medication schedule.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin and enoxaparin injections. For several residents, including those with type 2 diabetes mellitus and other complex medical conditions, the facility did not adhere to the prescribed practice of rotating subcutaneous injection sites. This failure was observed across multiple instances and involved several residents, such as Resident 12, 38, 49, 56, 116, and 125, who were administered insulin or enoxaparin without proper site rotation, contrary to physician orders and manufacturer guidelines. Resident 116, admitted with diagnoses including type 2 diabetes mellitus and acute kidney failure, was found to have insulin administered repeatedly in the same abdominal quadrants over a period of months. Similarly, Resident 38, with a history of functional quadriplegia and anoxic brain damage, received enoxaparin and insulin injections without site rotation, increasing the risk of adverse skin conditions. The facility's policies and procedures, which clearly outlined the necessity of site rotation to prevent complications such as lipodystrophy, were not followed by the nursing staff. Interviews with the facility's nursing staff, including Registered Nurse 4 and the Director of Nursing, confirmed the oversight in rotating injection sites, acknowledging it as a medication error. The facility's policies, as well as manufacturer instructions for insulin and enoxaparin, emphasized the importance of site rotation to minimize adverse effects. Despite these guidelines, the repeated failure to rotate injection sites was documented, highlighting a significant lapse in adherence to professional standards and physician orders.
Improper Management of Expired Medications
Penalty
Summary
The facility failed to properly manage and discard expired medications, specifically lorazepam and Aplisol vials, in accordance with manufacturer's requirements and facility policies. During an inspection of two medication rooms, surveyors found an open lorazepam vial for one resident stored in the refrigerator without a label indicating when it was opened, and another open lorazepam vial for a different resident that was expired but not discarded. Additionally, an open Aplisol vial for facility stock was found without a label indicating when it was opened, rendering it expired. Licensed Vocational Nurses (LVNs) and a Registered Nurse (RN) acknowledged the deficiencies during interviews, confirming that the lorazepam vials were either expired or lacked proper labeling, which is against the facility's policy. The LVNs and RN stated that expired medications could lead to decreased potency and sterility, potentially causing ineffective treatment or infections. The Director of Nursing (DON) also confirmed that the medications were not labeled or discarded as required, which could lead to accidental use and harm to residents. The facility's policies and procedures require that medications be stored and labeled according to manufacturer's recommendations, and that expired medications be immediately removed and disposed of. The failure to adhere to these policies resulted in the presence of expired and improperly labeled medications in the facility, increasing the risk of administering ineffective or harmful medications to residents.
Deficiency in Food Preparation and Presentation
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved flavor, appearance, and temperature, affecting the dietary intake of residents. Specifically, Resident 128, who was admitted with diagnoses including unspecified protein-calorie malnutrition and generalized weakness, was served food that was described as bland and unappetizing. On 8/20/2024, Resident 128 ate only 40% of their first meal, refused the second, and did not eat the third meal, citing the food's lack of appeal. Observations of the meal tray revealed unappetizing food items, including a bread roll, whole broccoli, and brown-colored shredded meat, which Resident 128 found unappealing. Further observations on 8/21/2024 revealed that the facility served mushy and overcooked Italian herb vegetables, soggy peach crisp, and a wilted red and green salad at an inappropriate temperature of 54°F. These items were part of the regular texture diet served to 20 residents. During a test tray conducted with the Dietary Director and Registered Dietitian, it was confirmed that the vegetables were overcooked, the salad was improperly served, and the peach crisp was not crispy as recommended. The Dietary Director acknowledged the issues, noting that the vegetables were left in the oven too long, leading to nutrient loss, and emphasized the importance of food presentation in stimulating residents' appetites. The facility's policies and procedures, as well as the diet manual, were reviewed and indicated that food should be prepared to maximize flavor, appearance, and nutritional value. However, the facility did not adhere to these guidelines, as evidenced by the poor quality and presentation of the meals served. The Director of Nursing highlighted the importance of serving palatable food to prevent potential weight loss and weakness among residents, underscoring the impact of the facility's failure to meet dietary standards.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate food preferences and provide appealing options of similar nutritive value to two residents, Resident 122 and Resident 84, during the Dining task. Resident 122, who was admitted with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, and unspecified dementia, was not offered a food substitute after expressing dislike for the meat served at lunch. Despite the resident's verbalization of dislike, neither the Licensed Vocational Nurse (LVN 10) nor the Treatment Nurse (TN 1) offered an alternative, even though the facility's care plan indicated that food substitutes should be offered if a resident refuses a meal or has poor intake. Resident 84, who had a dislike for pasta, was served vegetable soup containing pasta despite having a documented preference for no pasta. The resident's dietary preferences were clearly indicated on the lunch tray and in the dietary services progress notes. The Dietary Director acknowledged that the minestrone soup contained pasta and that the resident's preference should have been honored. The Director of Nursing also stated that residents should not be served foods they do not like and that their preferences should be respected to maintain their nutrition. The facility's policy on weight assessment and intervention, as well as the policy on resident food preferences, emphasize the importance of considering resident choices and preferences to prevent undesirable weight loss and ensure good nutrition. However, in these instances, the facility staff did not adhere to these policies, resulting in a failure to meet the nutritional needs and respect the food preferences of the residents involved.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The walk-in refrigerator, walk-in freezer, and dedicated ice cream freezer lacked separate thermometers apart from the built-in ones, which was confirmed by the Dietary Director (DD) and the Director of Nursing (DON). This absence of separate thermometers could prevent the facility from accurately monitoring temperatures, potentially leading to food spoilage. Additionally, two dented cans were found in the non-dented can area in the dry storage, which the DD acknowledged should have been sorted into a designated area for dented cans to prevent cross-contamination. Further observations revealed that the fire sprinkler in the walk-in refrigerator had dust and dirt buildup, which the DD admitted was unacceptable as it could contaminate food. The mixer used for food preparation had dry food buildup and residue, indicating it was not cleaned after its last use. The DD stated that the mixer should be cleaned after each use to prevent cross-contamination. Additionally, pans in the clean area had burnt food residue, which the DD recognized as a potential source of physical contamination. The kitchen hood also had dust buildup, which the DD noted could fall into uncovered pots and pans, leading to cross-contamination and posing a fire hazard. The facility's policies and procedures, as well as the Food Code 2017, emphasize the importance of maintaining cleanliness and proper storage practices to prevent contamination and ensure food safety. These deficiencies had the potential to result in harmful bacteria growth and cross-contamination, affecting 117 of 161 medically compromised residents who received food and ice from the kitchen.
Deficiency in Policy for Outside Food Storage
Penalty
Summary
The facility failed to have a comprehensive policy regarding the use and storage of food brought to residents by family and other visitors. The existing policy did not include the facility's responsibility for storing such food, stating that the facility cannot store outside food. This deficiency was identified during a review of the facility's Policies and Procedures, which indicated that all food brought into the facility must be cleared through the charge nurse and that perishable food kept at bedside should not exceed one meal that can be consumed within four hours. The policy aimed to ensure compliance with diet orders and prevent foodborne illness, but it lacked provisions for safe storage of perishable items. Interviews with facility staff, including the Dietary Director, Licensed Vocational Nurse, Director of Nursing, and Administrator, revealed inconsistencies in the handling and storage of outside food. The Dietary Director acknowledged the lack of refrigeration for outside food, while the Licensed Vocational Nurse mentioned a refrigerator in the kitchen but not in other units. The Director of Nursing and Administrator both emphasized the importance of consuming perishable food within four hours and encouraged families to bring food in single-serving portions. Despite these efforts, the absence of a clear policy and adequate storage facilities posed a risk of food spoilage and potential foodborne illness, affecting 117 of 161 residents who could experience decreased food intake, weight loss, and psychosocial harm.
Unlicensed COTA Performed Treatments
Penalty
Summary
The facility failed to ensure that a Certified Occupational Therapy Assistant (COTA) had an active California occupational therapy license while performing occupational therapy treatments. The COTA's license expired, yet they continued to work at the facility for at least three months. The Director of Rehabilitation (DOR) confirmed that the COTA's license was expired according to the California Board of Occupational Therapy (CBOT) website, and the facility had not received any written confirmation from CBOT allowing the COTA to continue practicing. Despite this, the COTA was still scheduled to work and perform treatments. The Director of Nursing (DON) stated that the rehabilitation staff were contracted through a rehabilitation company, and the facility was expected to follow the company's policies, which required all occupational therapists to have an active license. The facility's job description for a COTA and its policy on credentials validation both indicated that a valid license was necessary. The DOR acknowledged that the COTA should not have been scheduled to work without an active license, and the facility's policy required deactivation of access for employees with expired credentials.
Inaccurate Documentation in Resident Care Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for four residents, leading to discrepancies in documentation and potential impacts on resident care. For Resident 122, a Certified Nursing Assistant (CNA) inaccurately documented the resident's meal intake as 100% despite observations and interviews indicating the resident did not consume all the food, specifically the meat portion. This miscommunication between staff members resulted in inaccurate charting, which could affect the resident's nutritional assessment and care planning. Resident 6's records were also inaccurately documented, particularly regarding the use of a right knee splint and ankle foot orthoses (AFOs). The Restorative Nursing Aide (RNA) failed to document when the resident did not tolerate the splint, and the RNA Weekly Summary inaccurately reflected the frequency of splint application. This lack of accurate documentation could hinder the assessment of the resident's joint mobility and the effectiveness of the restorative nursing program. Similarly, Residents 125 and 138 experienced inaccuracies in their RNA documentation. Resident 125's records incorrectly indicated the application of splints and hand rolls, which were not actually used during treatment sessions. For Resident 138, the RNA documentation failed to specify which splints were applied and did not accurately record the duration of use or completion of range of motion exercises. These documentation errors could lead to misinterpretations of the residents' conditions and the effectiveness of their care plans.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue was the improper handling of medical equipment, such as oxygen tubing and urinary catheter bags, which were found touching the floor. This was observed in the cases of Resident 74 and Resident 121, where the oxygen tubing and urinary catheter bag, respectively, were in contact with the floor, posing a risk of infection. The staff, including the Director of Nursing, acknowledged that these practices were not in line with infection control protocols. Another deficiency involved the improper use of personal protective equipment (PPE) by staff members. Licensed Vocational Nurse 1 was observed administering medication to residents on enhanced barrier precautions without properly securing the gown at the waist, which could lead to exposure to contaminants. Similarly, Certified Nursing Assistant 2 failed to wear a gown while providing care to a resident on enhanced barrier precautions, contrary to the facility's policy requiring gown and glove use during high-contact activities. Additionally, the facility was found to have inadequate supplies and improper storage practices that could compromise infection control. The Central Supply Staff reported insufficient surgical masks to meet the two-week supply requirement, and linen carts were covered with permeable materials that did not adequately protect the linens from environmental contaminants. Furthermore, the facility's water management practices were inadequate, with water temperatures recorded below the recommended levels to prevent Legionella growth, as noted by the Administrator and Infection Preventionist.
Failure to Administer Prescribed Enteral Feeding Formula
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two residents. Both residents, who had severely impaired cognition and required total assistance with activities of daily living, were receiving tube feeding. The facility did not ensure that the prescribed enteral feeding formula, Jevity 1.2, was administered as ordered. Instead, the residents were given Fibersource HN without a physician's order due to Jevity 1.2 being out of stock. The issue arose when Registered Nurse 3 used Fibersource HN as a substitute for Jevity 1.2 without notifying the physician or obtaining an order for the change. This substitution was made because Jevity 1.2 was on back order, and the facility did not have a projected date for its availability. The lack of communication and failure to follow protocol led to the residents receiving a different formula than prescribed, potentially affecting their caloric intake and nutritional needs. The facility's policy and procedure for enteral feeding monitoring and administration require that all enteral feeding formulas have a physician's order and that the formula type, rate, and total to be delivered are checked against the order before administration. However, these procedures were not followed, as evidenced by the observations and interviews conducted with the nursing staff and the Director of Nursing. The failure to adhere to these protocols placed the residents at risk for complications associated with enteral feeding.
Failure to Properly Administer IV Fluids
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards of practice for a resident with an intravenous (IV) catheter. Specifically, the facility did not indicate the insertion date and the licensed nurse's initials on the peripheral intravenous line (PIV) dressing for a resident. Additionally, the facility failed to place a sterile injection cap over the injection port of the PIV line. These deficiencies were observed during a random inspection of residents with IV catheters, placing the resident at risk for complications such as inflammation of the vein and infection. The resident involved had a history of chronic respiratory failure, paraplegia, and anoxic brain damage, and was admitted to the facility with severely impaired cognition, requiring total assistance with all activities of daily living. The physician's orders specified that peripheral site care should occur every 96 hours, with the PIV catheter sites changed accordingly. However, during observations, it was noted that the PIV line on the resident's right foot lacked the necessary documentation and sterile injection cap, as confirmed by both a Licensed Vocational Nurse and a Registered Nurse. The facility's policy required the date, time, and initials to be written on the dressing label, which was not adhered to in this instance.
Failure to Provide Proper Tracheostomy Care
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for two residents with tracheostomies. Resident 468, admitted with diagnoses including dependence on a respirator and pneumonia, was observed without a fenestrated gauze under the tracheostomy flange, which is essential to protect the skin from breakdown. This observation was confirmed by a respiratory therapist and acknowledged by the Director of Nursing, who stated that the gauze should have been in place to prevent infection and pressure injury. Similarly, Resident 112, with chronic respiratory failure and a tracheostomy, was also found without a fenestrated gauze under the tracheostomy flange. The resident's care plan highlighted the risk of excoriation around the trach stoma site and included interventions to keep the area clean and dry. Despite this, the necessary gauze was not applied, as observed by a respiratory therapist. The facility's policy on tracheostomy care, which mandates the use of a fenestrated gauze pad, was not followed, leading to a deficiency in the care provided to these residents.
Failure to Address Consultant Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's (CP) recommendation for a Medication Regimen Review (MRR) was reviewed, addressed, or carried out according to facility policy for one of the sampled residents, Resident 56. The CP's note, dated June 26, 2024, recommended re-evaluating the use of pantoprazole, a medication prescribed for Gastro-Esophageal Reflux Disease (GERD), due to potential long-term side effects. However, there was no documented response from a physician, and the note was not signed or dated by a physician, indicating that the recommendation was not acted upon within the required timeframe. During interviews, both a Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the MRR notes should be addressed within 30 days, but this was not done for Resident 56. The facility's policy requires that recommendations from the CP be acted upon and documented by the facility staff or prescriber, but this did not occur, leading to a failure to provide optimal treatment for the resident's condition. The oversight increased the risk of adverse effects from the continued use of pantoprazole without re-evaluation.
Failure to Monitor Melatonin Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not adequately monitoring the use of Melatonin. The resident, who was diagnosed with depression and had cognitive impairments, was prescribed Melatonin to regulate circadian rhythm. However, the facility did not monitor the resident's hours of sleep or assess the effectiveness and side effects of the medication since July 8, 2024. This lack of monitoring was identified during a review of the resident's care plan and medication administration records, which showed that the goal of achieving six hours of sleep per night was not being tracked. The facility's Consultant Pharmacist had recommended updating the indication for Melatonin use and monitoring sleep hours to facilitate drug therapy monitoring, but these recommendations were not documented or followed through. The Director of Nursing confirmed the absence of documentation for sleep monitoring and acknowledged that the indication for Melatonin was not updated. This oversight resulted in the potential for the resident to receive unnecessary medication without proper evaluation of its effectiveness or side effects.
Delayed Meal Service for Resident
Penalty
Summary
The facility failed to provide meals at regular times comparable to normal mealtimes in the community for Resident 162. This deficiency was identified during an investigation under the dining observation care area. Resident 162, who was admitted with diagnoses including type two diabetes mellitus and heart failure, was served his lunch tray after the facility's scheduled lunch time. The facility's policy indicated that lunch should be served between 12:00 p.m. and 12:45 p.m., but Resident 162 reported receiving his meal at 1:00 p.m., which was confirmed by observations and interviews with staff. The Director of Nursing acknowledged that Resident 162's meal was distributed late, which could potentially affect the temperature of the food and the resident's psychosocial wellbeing. The facility's policy emphasized the importance of serving meals on time to meet residents' nutritional needs and ensure they feel respected. The delay in serving meals was observed to affect not only Resident 162 but also adjacent rooms, indicating a broader issue with meal distribution timing in the facility.
Deficient Pest Control Program Leads to Ant Infestation in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in a resident's room. The resident, who was admitted with diagnoses including type two diabetes mellitus and heart failure, reported feeling uncomfortable due to the ants and expressed concern about the cleanliness of the room, particularly after his roommates left food debris. The ants were observed in the corner of the room, near a doorway leading to an outdoor area. The Maintenance Supervisor confirmed the presence of ants and noted that the facility's contracted pest control service had visited the same day. The pest control service recommended keeping floors clean from food debris and ensuring trash containers were covered to prevent pest entry. The facility's policy indicated an ongoing pest control program, but the presence of ants in the resident's room suggested a lapse in its effectiveness. The Director of Nursing acknowledged that ants should not be present in residents' rooms as they could be a source of infection and discomfort.
Failure to Accurately Code MDS for Resident with PTSD
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The MDS assessments dated 10/16/2023, 1/16/2024, and 4/17/2024 did not include the resident's PTSD diagnosis, despite it being documented in the resident's Admission Record and Psychiatric Progress Notes. This oversight was identified during a review of the behavioral-emotional care area for the resident, who was admitted and readmitted to the facility with diagnoses including PTSD, schizophrenia, and dementia. The deficiency was confirmed during an interview and record review with the Minimum Data Set Coordinator, who verified that the resident's PTSD diagnosis was not coded in the Quarterly Assessments. The Director of Nursing acknowledged that all MDS assessments should be coded accurately to reflect the resident's current health status and ensure the provision of necessary care and services. The facility's policy on resident assessments requires all individuals completing any portion of the MDS to sign the document, attesting to the accuracy of the information provided.
Room Capacity Exceeded in Resident Room
Penalty
Summary
The facility failed to ensure that one of its resident rooms accommodated no more than four residents, as required by regulations. Room [ROOM NUMBER] was observed to have five beds and housed five residents, despite measuring 419.06 square feet and having ample space for beds, overbed tables, dressers, and equipment. During observations and interviews, neither the residents nor the staff reported any issues regarding the room size. The facility had previously submitted a waiver letter and a Client Accommodation Analysis Form, both indicating an approved capacity of five residents for the room. The facility also submitted a written request for a continued waiver. The facility's policy on bedrooms, last reviewed in April 2024, stated that all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, three rooms were identified as not meeting the 80 square feet per resident requirement. Room 19, which housed four residents, provided only 72.7 square feet per resident, while rooms 22 and 23, each accommodating three residents, offered 71.7 and 71.2 square feet per resident, respectively. The minimum required square footage for a three-bed room is 240 square feet, and for a four-bed room, it is 320 square feet. Despite the deficiency, during a Resident Council meeting and staff interviews, no concerns were raised regarding the room sizes. Observations also indicated that residents had ample space to move freely, and there was sufficient space for nursing staff to provide care. The facility had submitted a request for a waiver, arguing that the room sizes did not adversely affect residents' health and safety or impede their well-being. However, the facility's policy requires that all bedrooms meet federal and state requirements, which include the specified square footage per resident.
Failure to Obtain Informed Consent for Restraint Use
Penalty
Summary
The facility failed to obtain informed consent from a resident or their responsible party before applying a self-release seat belt, which is considered a restraint, to a resident in a wheelchair. The resident, who was admitted with diagnoses including muscle weakness, type 2 diabetes mellitus, and obsessive-compulsive behavior, was moderately impaired and required assistance with various activities of daily living. On the day of the incident, the resident's blood sugar was low, and they were observed to be leaning forward with an unsteady gait, prompting staff to apply the self-release seat belt without prior consent. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) involved acknowledged that the resident's family was not informed before the application of the restraint. The restraint was applied after the resident was found to be agitated and unable to be redirected, with concerns about potential falls. The restraint was applied at 5 p.m. and discontinued by 8 p.m. after the family member objected to its use. The facility's policy requires informed consent and notification of the resident's family in such situations, which was not followed in this case. Interviews with the family member and staff confirmed that the family was not notified or consent obtained before the restraint's application. The facility's policy and the manufacturer's guidelines for the self-release belt emphasize the need for informed consent and the use of restraints only when necessary and as a last resort. The failure to obtain consent and notify the family violated the resident's rights to be informed and participate in their treatment decisions.
Failure to Obtain Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without obtaining informed consent from the resident's representative. The incident involved a resident who was admitted with diagnoses including muscle weakness, type 2 diabetes mellitus, and obsessive-compulsive behavior. The resident was assessed as having a high fall risk and required assistance with various activities of daily living. On the date of the incident, the resident was noted to be agitated and had an unsteady gait, prompting staff to apply a self-release seat belt for positioning without prior consent from the resident's representative. The self-release seat belt was applied after a Licensed Vocational Nurse (LVN) observed the resident leaning forward and attempting to get up without assistance, which raised concerns about potential falls. The LVN, along with a Registered Nurse (RN), obtained a physician's order for the restraint but did not inform or obtain consent from the resident's family or representative before its application. The restraint was applied at 5 p.m. and was removed later that evening after the family expressed their refusal of its use. Interviews with the Director of Nursing (DON) and other staff confirmed that the family was not notified prior to the application of the restraint, and the resident was unable to unbuckle the self-release belt, classifying it as a restraint. The facility's policy and the manufacturer's guidelines for the restraint emphasize the need for informed consent and the use of restraints only when all other options have failed. The failure to obtain informed consent before applying the restraint violated the resident's rights and the facility's policies.
Failure to Develop Care Plan for Restraint Use
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident regarding the use of a self-release seat belt. The resident, who was admitted with conditions including muscle weakness, type 2 diabetes mellitus, and obsessive-compulsive behavior, was moderately impaired and required assistance with various activities of daily living. Despite having a physician's order for a self-release seat belt for positioning due to an unsteady gait and frequent falls, the facility did not create a care plan for its use. During an interview, the Director of Nursing (DON) confirmed the absence of a care plan and acknowledged that the self-release belt was considered a restraint since the resident was unable to unbuckle it independently. The manufacturer's guidelines for the self-release belt indicated that if a patient cannot easily self-release, it is considered a restraint and must be prescribed by a physician. The facility's policy on physical restraints required a care plan specifying the reason for the restraint, type, and conditions of use. However, the facility did not adhere to these guidelines, as evidenced by the lack of a care plan for the resident's restraint use. This oversight had the potential to negatively impact the resident's physical wellbeing and restrict their freedom of movement.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to follow its policy and procedure for notifying a physician of a significant change of condition (COC) for a resident. The resident, who had a tracheostomy, experienced a partial displacement of the tracheal tube. A respiratory therapist attempted to replace the tube with the same size but was unsuccessful and instead used a smaller tube. Despite diminished breath sounds and minimal airflow, the registered nurse did not notify the resident's physician as required by the facility's policy. The resident was later found with breathing difficulties, unappreciated vital signs, and began to turn blue. Paramedics were called and arrived shortly after, but the resident was pronounced dead. The failure to notify the physician promptly about the change in the resident's condition and the use of a smaller tracheal tube contributed to the resident's decline and eventual death. Interviews with staff revealed that the registered nurse did not contact the physician because they believed the physician would not respond at that time. The facility's policy required immediate notification of the physician in the event of a change of condition, but this was not followed, leading to the resident's unaddressed respiratory distress and subsequent death.
Removal Plan
- The DON provided one on one in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident's COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC.
- The DON and Sub-Acute unit RN 1 initiated in-service/education for all interdisciplinary staff regarding: the proper procedures for identifying a resident's COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions.
- The DON and a RN reviewed 15 residents' medical records with a change of condition. All documentation reflected that the physician was notified promptly regarding the change of condition as required.
- The DON and the Quality Assurance Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress, identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record.
- All 43 residents with tracheostomy tubes were assessed by the respiratory therapists and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation.
- The DON/Designee will randomly review at least 10 residents' medical records with COC per month for 3 months and then quarterly thereafter.
Failure in Tracheostomy Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, leading to a critical incident. The resident, who had a history of cerebral infarction, tracheostomy, dysphagia, encephalopathy, and respiratory failure, experienced a partial displacement of their tracheal tube. Despite the intervention of a respiratory therapist who replaced the tube with a smaller size, the resident exhibited diminished breath sounds and minimal airflow, indicating respiratory distress. The situation escalated when the resident was found with breathing difficulties, unappreciated vital signs, and signs of cyanosis. The staff failed to promptly notify the physician or take appropriate actions to address the resident's change of condition. The paramedics were called but arrived to find the resident already deceased, with rigor and lividity present. Interviews with staff revealed a lack of communication and failure to follow protocols for notifying the physician and obtaining necessary medical imaging to confirm the tracheal tube placement. The staff did not adequately monitor the resident's condition or respond to the respiratory therapist's recommendations, contributing to the resident's deterioration and eventual death.
Removal Plan
- The DON provided one on one in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident's COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC.
- The DON and the Sub-Acute Unit RN 1 initiated in-service/education for all interdisciplinary staff regarding the proper procedures for identifying a resident's COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions.
- The DON and RN reviewed 15 residents' medical records with a change of condition. All documentation reflected that the physician was notified promptly regarding the change of condition as required.
- The DON and the Quality Assurance Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress, identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record.
- All 43 residents with tracheostomy tubes were assessed by the respiratory therapist and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation.
- The DON/Designee will randomly review at least 10 residents' medical records with COC charts per month for 3 months and then quarterly thereafter.
- The Director of Staff Development reviewed all RNs competencies to ensure completion. No other RNs were affected.
- RN 1 will receive and pass competency training monthly for 3 months and then annually thereafter. The DON/DSD/Designee will repeat in-service training monthly for 3 months and then quarterly and as needed regarding the proper procedures for identifying a resident's change of condition, reporting a change of condition, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a change of condition, calling the paramedics in a timely manner during an emergency, and contacting the medical director if a physician does not answer.
- The DON/Designee will complete 10 competencies per month for IDT staff using the COC Competency and Validation form.
- Any negative findings of the residents' medical records audit will be reported by the Medical Records Director/Designee to the Quality Assurance Committee monthly for 3 months and then quarterly thereafter for review and further action as needed.
Failure to Follow Change of Condition Protocols Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) had the necessary skills and knowledge to provide appropriate care to a resident experiencing a change of condition. The resident, who had a tracheostomy and was at risk for respiratory distress, experienced a tracheal tube displacement. A respiratory therapist (RT) replaced the tube with a smaller size, resulting in diminished breath sounds and minimal airflow. Despite being advised to notify the medical doctor (MD) for further intervention, the RN did not secure an order for an x-ray to confirm the new tube placement or notify the MD promptly. Later, the resident was found with breathing difficulties and unappreciated vital signs. The RN delayed calling emergency services, waiting six minutes before contacting paramedics. Upon arrival, the paramedics found the resident with signs of rigor and lividity, and the resident was pronounced dead shortly after. Interviews revealed that the RN did not follow the facility's policy for change of condition and cardiopulmonary resuscitation, which required immediate notification of the physician and emergency services. The resident had a history of cerebral infarction, tracheostomy, dysphagia, encephalopathy, and respiratory failure. The care plan indicated the need for special tracheal tube care and prompt notification of the physician in case of decannulation or respiratory distress. The RN's failure to act according to the facility's policies and procedures contributed to the resident's decline and eventual death.
Removal Plan
- The DON provided one on one in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident's COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC.
- The DON and the Sub-Acute unit RN 1 initiated in-service/education for all interdisciplinary staff regarding the proper procedures for identifying a resident's COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions.
- The DON and RN reviewed 15 residents' medical records with a change of condition. All documentation reflected that the physician was notified promptly regarding the change of condition as required.
- The DON and the Quality Assurance Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress, identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record.
- All 43 residents with tracheostomy tubes were assessed by the respiratory therapist and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation.
- The DON/Designee will randomly review at least 10 residents' medical records with COC charts per month for 3 months and then quarterly thereafter.
- The Director of Staff Development reviewed all RNs competencies to ensure completion. No other RNs were affected.
- RN 1 will receive and pass competency training monthly for 3 months and then annually thereafter. The DON/DSD/Designee will repeat in-service training monthly for 3 months and then quarterly and as needed regarding the proper procedures for identifying a resident's change of condition, reporting a change of condition, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a change of condition, calling the paramedics in a timely manner during an emergency, and contacting the medical director if a physician does not answer.
- The DON/Designee will complete 10 competencies per month for IDT staff using the COC Competency and Validation form.
- Any negative findings of the residents' medical records audit will be reported by the Medical Records Director/Designee to the Quality Assurance Committee monthly for 3 months and then quarterly thereafter for review and further action as needed.
Inaccurate Posting of Daily Staffing Information
Penalty
Summary
The facility failed to accurately post the daily staffing information in the sub-acute unit on 5/14/2024. During an observation and interview with the Infection Preventionist (IP) at 4:45 p.m., it was noted that the posted nursing staffing information was dated for 5/15/2024 instead of the current date. The IP confirmed that the correct staffing information for 5/14/2024 was placed behind the information for the following day. This discrepancy was further confirmed during a subsequent observation and interview with the Director of Nursing (DON) at 5:06 p.m., who acknowledged that the posted information was incorrect. The DON explained that the Director of Staff Development (DSD) was responsible for posting the nursing staffing information and had posted the information for the next day before leaving the facility at 3 p.m. The facility's policy, last revised in August 2022, requires that staffing data be posted daily for each shift, including the number of licensed and unlicensed nursing personnel responsible for direct resident care. The policy specifies that this information should be posted within two hours of the beginning of each shift and must include the current date. The failure to adhere to this policy resulted in the potential for residents, visitors, and staff to be unaware of the actual staffing levels available to provide care on 5/14/2024.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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