Sunland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunland, California.
- Location
- 8647 Fenwick Street., Sunland, California 91040
- CMS Provider Number
- 056031
- Inspections on file
- 61
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Sunland Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall resulting in a forehead injury and severe pain. Staff initiated a 72-hour neuro check protocol, but the ADON later determined that the required 30-minute and subsequent interval assessments were not performed or documented at the correct times. After the resident was transferred to and then returned from an acute care hospital, the 72-hour neuro checks were not resumed and documented according to the facility’s specified timetable, contrary to facility policies on neurological checks and documentation accuracy.
A resident with severe cognitive impairment and a history of fracture had a PRN order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain rated 1–4/10. After an unwitnessed fall causing a forehead bump and severe pain rated 8/10, an LVN administered acetaminophen despite the order’s pain-scale parameters and did not contact the physician for alternative pain management. Documentation on the SBAR and MAR showed acetaminophen was given for pain documented as 7–8/10, contrary to the prescribed range and the facility’s pain management and medication administration policies.
The facility failed to reconcile and document controlled medications in five emergency kits and two medication carts, resulting in missing accountability logs and discrepancies in medication counts for a resident prescribed lacosamide for seizures. Nursing staff did not consistently sign off on controlled medication administration as required by policy, and required shift-change reconciliation of emergency kits was not performed.
Surveyors found that staff failed to document medication refrigerator temperatures twice daily as required, and did not remove expired budesonide inhalation solutions from a medication cart. These actions were not in accordance with facility policy or manufacturer guidelines, affecting two residents who required proper medication storage and administration.
A nurse left a medication cart computer unlocked and unattended, allowing potential access to residents' EHRs. Staff interviews confirmed that computers should be locked when unattended to protect resident privacy, in accordance with facility policy.
A resident's tray table was found dirty and cluttered during mealtime, while two residents near the smoking patio were repeatedly exposed to a loud alarm triggered by staff entering and exiting the gate. Staff and the DON confirmed that these conditions did not meet expectations for cleanliness and a calm, homelike environment.
Three residents did not have individualized care plans addressing their specific needs and risks. Two residents who smoked lacked care plans specifying the required level of supervision during smoking, and another resident prescribed Klonopin did not have a care plan addressing the medication's black box warning. Facility staff confirmed that these care plans were not resident-centered and did not provide clear guidance for staff interventions.
The facility did not ensure a safe environment for several residents by failing to accurately assess fall risk for a resident with a recent fall, leaving disinfectant wipes within reach of a cognitively impaired resident, and allowing two residents to possess lighters and cigarettes despite facility policy. In addition, smoking risk assessments for these residents were unclear, leading to confusion among staff about required supervision and safety interventions.
Three residents experienced medication errors when nursing staff administered medications at incorrect times or provided the wrong formulation, resulting in a medication error rate of 12%. Staff acknowledged administering medications outside the required time window and not following physician orders, despite facility policies mandating accurate and timely medication administration.
A resident with severe cognitive impairment and no decision-making capacity was placed on a wander guard, a physical restraint, without obtaining informed consent from the responsible party. The facility initially documented the resident as self-responsible due to lack of family information, but after learning of family involvement, did not secure the required written consent, contrary to facility policy.
The facility did not maintain a copy of an advance directive in the medical record for a resident with Alzheimer's disease and hypertension, and failed to provide written information about advance directives to another resident with sepsis and pyelonephritis. Staff interviews confirmed that required documentation and information were not provided or available as per facility policy.
A resident with severe cognitive impairment and a history of elopement risk was placed on one-to-one monitoring after removing a wander guard, but the responsible party was not notified of this significant change in care. Facility staff and documentation confirmed the lack of communication, despite policy requiring notification and documentation of such changes.
A resident with severe cognitive impairment and diabetes was not given a completed SNF ABN form prior to the end of Medicare Part A coverage. The responsible party was notified and signed the form 19 days after coverage ended, rather than at least 72 hours in advance, and the required options regarding care and financial responsibility were not selected. The facility lacked a policy for beneficiary notices and did not follow CMS guidelines for timely notification.
A resident with severe cognitive impairment and a history of stroke was placed on a wander guard, classified as a physical restraint by facility policy, without consistent documentation or evidence of wandering behavior. Despite physician orders and hourly monitoring, staff interviews and records confirmed the resident refused the device and did not attempt to leave the facility. The facility failed to provide required documentation supporting the use of the restraint, resulting in a deficiency.
A resident with severe cognitive impairment and no decision-making capacity was admitted with conditions including hemiplegia and aphasia. The facility failed to adequately involve the resident's responsible party in IDT care plan meetings, making only a single phone call attempt without further follow-up, despite policy requiring efforts to ensure family or representative participation.
A resident with diabetes consistently received insulin injections in the same abdominal site without rotation, contrary to professional standards and facility policy. Record review and staff interview confirmed repeated administration in the left lower quadrant, despite the facility's procedures requiring site rotation to prevent injury.
A resident with dysphagia and severe cognitive impairment did not receive a physician-ordered large portion breakfast due to a breakdown in communication between nursing and kitchen staff. The order, recommended by the RD and approved by the physician, was not relayed to the kitchen, resulting in the resident receiving regular portions instead of the prescribed large portion for several weeks.
A resident with respiratory failure and other chronic conditions did not receive oxygen therapy at the flow rate ordered by the physician. The oxygen was set below the prescribed range, and staff confirmed that the physician's order was not followed, contrary to facility policy requiring medications to be administered as prescribed.
Surveyors found that the facility did not maintain the required concentration of quaternary ammonium sanitizing solution for cleaning kitchen surfaces, with repeated tests showing levels below 100 ppm instead of the required 200 ppm. Additionally, a resident with hypertension and diabetes was observed with leftover food from outside left unrefrigerated at the bedside for over 24 hours, contrary to facility policy. These deficiencies were confirmed through staff interviews, direct observation, and policy review.
A resident with multiple health conditions and impaired cognition was not offered the required pneumococcal vaccine dose, and the necessary consent form was missing from their record. Staff interviews confirmed the oversight, which was not in accordance with the facility's policy to evaluate and offer the vaccine to all residents.
A resident with impaired cognition and significant medical conditions did not receive a COVID-19 booster vaccine after their representative provided consent. Despite documentation of consent and facility policy requiring vaccination, no physician order was placed and the vaccine was not administered, as confirmed by both the IPN and DON.
A resident with multiple medical conditions was observed self-administering medications at bedside without an interdisciplinary team (IDT) assessment or physician order, contrary to facility policy. Staff confirmed that the resident had been self-administering since admission, and the required evaluation and documentation for self-administration were not completed.
A resident with severe cognitive impairment and multiple medical conditions exhibited a long-standing behavior of spitting, which was managed informally by staff but not addressed in a formal care plan. The DON was unaware of the behavior, and the required comprehensive care plan did not include interventions or measurable objectives for this issue, contrary to facility policy.
A resident with multiple medical conditions, including metabolic encephalopathy and diabetes, was administered lorazepam as ordered for anxiety, but the administration was documented only on the MAR and not on the Individual Count Sheet Record as required by facility policy. The DON confirmed the discrepancy, which involved a lack of immediate documentation on the accountability record for a controlled substance.
Staff failed to properly account for and secure a discontinued bottle of lorazepam prescribed to a resident with multiple medical conditions, resulting in the medication going unaccounted for. The prescription number on the medication record did not match the bottle found in the medication room, and the DON confirmed the missing bottle was not received for safekeeping or destruction as required by facility policy.
A resident with end stage renal disease and diabetes was repeatedly served meals containing carbohydrates despite documented preferences and dietary orders to avoid them. The facility did not update the resident's dietary profile during the required quarterly review, and staff acknowledged that the resident's food preferences were not honored, in violation of facility policy.
Surveyors found that clear storage cups of sugar-free gelatin, prepared for residents with diabetes, were not labeled or dated according to facility policy. Both the Dietary Aide and Director of Dietary Services confirmed the labeling requirement, and the deficiency had the potential to affect a large number of residents receiving food from the kitchen.
A resident with hemiplegia, a history of falls, and moderate cognitive impairment was found to have a non-functioning call light, which was only operable after being plugged in by a nurse supervisor. Facility policy required that all residents be shown how to use the call light and that staff ensure it is within reach and operable, but this was not followed, resulting in the deficiency.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
A resident with cognitive impairment and multiple medical conditions was transferred to a hospital for a mental health evaluation without being provided the required bed hold notice. Facility staff confirmed that neither the resident nor their representative received written information about the bed hold policy prior to the transfer, despite facility policy requiring such notification.
A resident with severe cognitive and physical impairments was physically assaulted by a roommate with similar cognitive deficits, resulting in multiple facial and hand injuries that required hospital treatment. The incident occurred after the resident called for nursing assistance, prompting the roommate's aggressive response. Staff discovered the situation after hearing distress from the room, and the facility's abuse prevention policy was not effectively followed, leading to actual harm.
A resident with severe cognitive impairment and a history of psychosis experienced multiple episodes of yelling after discontinuation of Seroquel. Nursing staff documented the behavioral changes but did not notify the physician as required by facility policy, resulting in a failure to communicate a significant change in condition.
A resident with severe cognitive impairment and physical disabilities was struck by a roommate, resulting in facial injuries and hospital transfer. The facility failed to report the alleged abuse to the SSA within the required two-hour timeframe, submitting the report seven minutes late, contrary to its own policy and federal requirements.
A resident with dementia and psychosis had Seroquel discontinued, after which multiple episodes of yelling were documented. Despite facility policy and staff awareness of the need for ongoing behavioral monitoring and weekly progress notes, documentation was missing for two weeks, and there was no consistent assessment of the resident's psychosocial status following the medication change.
A resident with anxiety, dementia, and depression was given trazodone PRN for insomnia without a specified duration, contrary to facility policy requiring a 14-day limit and reevaluation. The DON confirmed the oversight, as the medication was administered multiple times without adhering to the policy.
The facility failed to maintain a safe environment by not addressing roof and ceiling damage, leading to water leaks in resident rooms and the kitchen. Several residents, including those with dementia and multiple sclerosis, were affected, with some refusing to move despite feeling unsafe. Observations revealed significant ceiling damage, and the facility's maintenance policies were not followed.
A facility failed to revise a care plan to include specific interventions for the use of a mechanical lift for a resident with cerebral infarction, hemiplegia, and hemiparesis. The care plan did not specify the need for two staff members to assist with transfers, as required by facility policy. Interviews with the MDSC and DON confirmed the oversight, indicating the care plan was not updated to meet the resident's specific needs, potentially affecting care provision.
A CNA in a LTC facility failed to provide the required two-person assistance when using a mechanical lift to transfer a resident with cerebral infarction and hemiplegia. The CNA operated the lift alone due to unavailability of staff, contrary to facility policy. The resident required total assistance for transfers, and the facility's policy mandated two staff members for safety.
A resident with severe cognitive impairment and a care plan requiring the call light to be within reach was found with the call light hanging off an overhead lamp, out of reach. A nurse confirmed the necessity of the call light for timely assistance, as per facility policy.
A resident with schizophrenia and anxiety was allegedly locked in a family room by the DON, witnessed by a CNA. The SSA was informed but did not report the incident immediately to the ADM, delaying the required report to the State Survey Agency. The facility's policy requires immediate reporting of abuse, which was not followed.
A facility failed to implement infection control practices by not labeling a resident's urinal bottles, which were found unlabeled during an observation. The resident, with COPD and hypertension, required assistance with hygiene. The facility's policies emphasized labeling personal items to prevent infection spread, which was not followed.
A resident with cerebral infarction, hypertension, and hypothyroidism was not informed of a TSH test result, which was conducted without a physician's order. The test result was significantly outside the normal range, and neither the resident nor their responsible party was notified, violating the resident's rights to be informed about their care and treatment.
A resident with cerebral infarction, hypertension, and hypothyroidism underwent a TSH test without a physician order, resulting in a significantly elevated TSH level. The facility's policy requires physician orders for diagnostic tests, which was not followed, posing a risk to the resident's care plan.
A resident experienced untreated pain due to a lack of monitoring and care for an IV line by RN 3. Despite complaints of pain and visible blood around the IV site, RN 3 continued administering antibiotics without checking the line's patency. The resident, with a complex medical history, required substantial assistance and had an IV line inserted for antibiotic treatment. The IV site was later found infiltrated and removed by RN 4. Interviews revealed RN 3's inaction, and the facility lacked a policy on IV administration.
A facility failed to set a low air loss mattress (LALM) correctly for a resident, risking skin breakdown, and did not measure another resident's heel ulcers for six weeks. The first resident's LALM was set for a higher weight than needed, without a physician's order. The second resident's heel ulcers were not measured, contrary to facility policy, hindering assessment of healing.
A facility failed to document pain assessments for a resident with a complex medical history, including meningitis and paraplegia, as ordered by the physician. Despite orders to assess pain every shift and administer hydrocodone-acetaminophen for severe pain, multiple instances of undocumented pain assessments were found in the MARs for July and August. The DON emphasized the need for complete pain assessments to evaluate pain and medication effectiveness, aligning with the facility's pain management policy.
A facility failed to monitor a resident for side effects of apixaban, an anticoagulant, as required by physician's orders and facility policy. The resident, with a history of cerebral infarction and hemiplegia, was not monitored for side effects such as bleeding and bruising during multiple shifts in July and August. Interviews with staff confirmed the oversight, which was against the facility's anticoagulation use policy.
A resident receiving Seroquel for schizophrenia was not consistently monitored for changes in behavior and side effects as required by physician orders. The MAR showed multiple instances where monitoring for conditions like Parkinsonism symptoms, akathisia, tardive dyskinesia, and cognitive impairment was not documented. This deficiency was confirmed by a nurse and the DON, highlighting a failure to adhere to the facility's psychotropic medication policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with indwelling devices, as no EBP signs were posted, and staff did not follow EBP protocols. Additionally, kitchen staff did not adhere to infection control policies, with a Dietary Manager handling food without a hairnet and a cook wearing dangly jewelry, both against the facility's dress code. These lapses posed risks of infection spread and foodborne illnesses.
A facility failed to ensure privacy for a resident during a blood sugar check and medication administration. An LVN did not close the privacy curtain, leaving the resident visible to their roommate and the hallway. The resident, with intact cognitive skills and requiring assistance with personal care, was admitted with type 2 diabetes. The LVN acknowledged the oversight, which violated the facility's policy on dignity and privacy.
Failure to Accurately Complete Required 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to provide resident-centered care and services by not accurately completing a required 72-hour neurological assessment following an unwitnessed fall experienced by Resident 1. Resident 1 had been admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the medial malleolus of the right tibia, and had severely impaired cognition per the most recent MDS. On the date of the incident, an SBAR Communication Form documented that Resident 1 had an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8 out of 10. A 72-hour neuro check list was initiated at 8:30 p.m. in accordance with facility practice for unwitnessed falls; however, during review, the Assistant Director of Nursing (ADON) identified that the required assessment intervals were not accurately completed. Specifically, the every-30-minute neurological checks were not performed at the correct times, as they should have occurred at 9:15 p.m. and 9:45 p.m., but were instead documented at 9:00 p.m. and 9:30 p.m. Further review of the clinical record showed that Resident 1 was transferred to an acute care hospital later that evening and returned to the facility the following morning at 5:15 a.m. The ADON stated that, based on the documented return time, the 72-hour neurological checks should have resumed upon arrival and followed specific four-hour and subsequent interval times over the next several days, but the documentation did not reflect that these intervals were followed as required. The facility’s policies titled "Neurological Checks" and "Documentation Principles" required that neurological checks be conducted for 72 hours after a fall with head impact, using the appropriate form and timetable, and that the clinical record be current, accurate, timely, and consistent with good medical and professional practice. The inaccurate timing and incomplete documentation of the neuro checks for Resident 1, as identified by the ADON during record review, constituted the deficiency.
Failure to Follow PRN Pain Medication Parameters After Resident Fall
Penalty
Summary
The facility failed to administer pain medication in accordance with a physician’s order based on a documented pain scale for one resident. The resident was admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the right medial malleolus. An MDS assessment indicated the resident had severely impaired cognition and required staff assistance with oral, toileting, and personal hygiene. The physician’s order, dated 6/29/2025, specified acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain rated 1–4 on a 0–10 pain scale. The resident’s care plan for chronic pain/discomfort included an intervention to provide consistent and sufficient pain medication tailored to the individual. On a date in December, the resident experienced an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8/10 on a pain scale. An SBAR form documented the fall, the severe forehead pain, and that an ice pack and Tylenol were provided, without specifying the dose. The MAR for that month showed that acetaminophen was administered at 8:45 p.m. for forehead pain with a documented pain level of 7/10. The LVN later stated the resident had reported pain at 8/10, that acetaminophen was given for this level of pain, and that the MAR entry of 7/10 was incorrect. During interview and record review, the ADON confirmed that acetaminophen 325 mg, two tablets, was administered for a reported pain level of 7/10, acknowledged that the order limited use to pain levels 1–4/10, and stated the physician should have been contacted for a stronger pain medication appropriate to the higher pain level. Facility policies on pain management and medication administration required pain assessment with documented ratings and administration of medications as prescribed by the physician.
Failure to Reconcile and Document Controlled Medications in Emergency Kits and Medication Carts
Penalty
Summary
The facility failed to reconcile and account for five medication emergency kits (eKITs) containing controlled medications (CMs) for the months of November and December 2025. This deficiency was observed in three medication rooms and one medication cart, where accountability logs for the reconciliation of CM inventory at every shift change were missing. Additionally, there were discrepancies in the count of CMs, specifically lacosamide, in two medication carts for a resident with a seizure disorder. The counts in the medication bubble packs did not match the documentation on the accountability logs, and there was no record of subsequent administrations to explain the missing doses. During observations and interviews, it was revealed that licensed nurses administered doses of lacosamide but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. Both nurses acknowledged that they did not follow the policy of signing each CM dose on the accountability log after preparing and administering the medication. The Assistant Director of Nursing and the Director of Nursing confirmed that the eKITs containing CMs were not reconciled at every shift change, and that the required accountability and reconciliation logs were not maintained for the specified period. The resident involved had a diagnosis of epilepsy and was prescribed lacosamide 200 mg twice daily for seizure disorder. The facility's policies required that all CMs, including those in emergency kits, be counted and documented at every shift change by two licensed nurses, and that administration of CMs be immediately recorded on the accountability record and the Medication Administration Record (MAR). These procedures were not followed, resulting in unaccounted doses and missing documentation for both individual resident medications and emergency kits containing controlled substances.
Failure to Monitor Vaccine Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly monitor and document the temperature of a medication refrigerator containing vaccines in one of the medication rooms. Specifically, the temperature log for the refrigerator in Medication Room Station 2 showed that temperatures were only recorded once daily over a specified period, despite facility policy and manufacturer guidelines requiring twice-daily monitoring. The Assistant Director of Nursing (ADON) confirmed that several licensed nurses did not monitor or document the refrigerator temperature as required, making it unclear whether the vaccines were stored within the recommended temperature range. Additionally, the facility failed to remove and discard expired budesonide inhalation solutions from a medication cart. An open foil pouch containing four remaining budesonide inhalation solutions for a resident with COPD was found stored at room temperature beyond the two-week period recommended by the manufacturer after opening. Both the LVN and the DON acknowledged that the expired medication should have been removed and that several licensed nurses failed to do so, contrary to facility policy and manufacturer instructions. The facility's policies require that medications and biologicals be stored according to manufacturer recommendations, with expired or deteriorated medications immediately removed from stock. The surveyors' review of the facility's policies and the manufacturer's guidelines confirmed that these requirements were not met in the instances observed, resulting in the presence of expired medications and inadequate monitoring of vaccine storage conditions.
Unattended Unlocked Computer on Med Cart Exposes Resident Records
Penalty
Summary
Licensed Vocational Nurse 3 (LVN 3) left the computer on the medication cart in Station 3 unlocked and unattended, providing potential access to residents' electronic health records (EHR). This was observed during a survey, where the computer screen was found open and accessible, allowing anyone to potentially view confidential resident information. Both Registered Nurse 5 (RN 5) and LVN 3 acknowledged that the computer should have been locked when unattended to prevent unauthorized access to residents' records. The Director of Nurses (DON) confirmed that facility policy requires licensed nurses to lock computers when leaving the medication cart to maintain residents' privacy. The facility's policy and procedure on Resident Rights, last reviewed on 5/14/2025, states that residents are to be assured confidential treatment of their financial and medical records. The failure to lock the computer, even when not displaying a specific resident's record, was recognized as a breach of this policy and had the potential to compromise the privacy of all residents in the facility.
Failure to Maintain Cleanliness and Minimize Excessive Noise in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three of five sampled residents. For one resident with severely impaired cognition and multiple medical diagnoses, the tray table used during mealtimes was observed to be dirty and cluttered with unnecessary items such as an opened disinfectant wipes container, gloves, masks, disposable undergarments, and plastic bags. This was confirmed by a registered nurse, who acknowledged that the tray table should be clean and uncluttered during meals, and by the Director of Nursing, who stated that residents' rooms should always be clean and clutter-free to promote a homelike environment. Additionally, two other residents, both cognitively intact and with various medical conditions, were affected by frequent activation of an alarm located near their rooms. The alarm, connected to the smoking patio gate, was triggered repeatedly as staff entered and exited through the gate to access laundry, maintenance storage, and the parking area. During a two-hour observation period, the alarm sounded 34 times. Staff interviews revealed that the alarm often activated because the time allowed to enter the deactivation code was insufficient. Both residents reported being disturbed by the frequent alarm noise, with one stating that the sound bothered him when his door was open and the other noting that he had become accustomed to the noise over time. The Director of Nursing confirmed that excessive noise from the alarm could disrupt the calm, homelike environment expected for residents, especially those with rooms near the smoking patio door. Facility policy requires maintaining a safe, clean, and comfortable environment for all residents.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed the specific needs and risks of three residents. For two residents with a history of smoking, the care plans did not specify the required level of supervision during smoking activities, despite facility policy and interdisciplinary team notes indicating that such details should be included. The care plans contained general interventions such as education on smoking risks and safe disposal of cigarette butts, but lacked individualized instructions regarding supervision or the use of safety equipment like smoking aprons. Both the RN and DON confirmed that the care plans were not resident-centered and did not provide staff with clear guidance on the necessary interventions to ensure safety during smoking. For another resident prescribed Klonopin, an antianxiety medication with a black box warning, the care plan did not address the specific risks associated with the medication. Although the resident had severe cognitive impairment and was dependent on staff for most activities of daily living, the care plan failed to mention the black box warning for Klonopin, which includes risks of abuse, addiction, dependence, and withdrawal reactions. Both the RN and DON acknowledged that the care plan should have included these details to enable appropriate monitoring and staff awareness of the medication's dangers. The facility's policies and procedures require that comprehensive, resident-centered care plans be developed for each resident, including measurable objectives and timeframes based on the comprehensive assessment. The deficiencies identified in the report were due to the omission of individualized interventions and failure to address specific risks in the care plans, as observed during interviews and record reviews with facility staff.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for four of eight sampled residents. For one resident with a history of falls and multiple diagnoses including acute respiratory failure, depression, schizophrenia, and generalized muscle weakness, the fall risk assessment was not accurately completed. Despite documentation of a recent fall and reported pain, the fall risk evaluation did not reflect this incident, leading to a lack of appropriate identification and intervention for fall risk as outlined in the facility's policies. Another resident with severely impaired cognition and chronic medical conditions was found to have an open container of disinfectant wipes left unattended and within reach on their tray table. Staff acknowledged that it was unsafe for this resident to have access to chemicals, and facility policy prohibits residents from having flammable or unsafe chemicals at the bedside. The presence of the disinfectant wipes posed a risk of accidental poisoning, especially given the resident's cognitive impairment. Additionally, two residents were found in possession of lighters and cigarettes, contrary to the facility's smoking policy, which requires all smoking materials to be stored in locked areas and prohibits residents from carrying such items. Staff interviews and documentation revealed that the smoking risk assessments for these residents were unclear and did not specify whether they required supervision while smoking. This lack of clarity led to confusion among staff regarding the necessary safety interventions and resulted in residents possessing smoking materials unsupervised, increasing the risk of fire hazards.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12% error rate during the observed period. Three medication errors were identified out of 25 opportunities, affecting three residents. Specifically, one resident received aspirin at a time different from the physician's order, another received a multivitamin with minerals instead of the prescribed multivitamin without minerals, and a third resident received carvedilol at a time inconsistent with the physician's order. Observations and interviews revealed that the errors were due to deviations from prescribed medication administration times and incorrect medication selection. Nursing staff acknowledged administering medications outside the facility's 60-minute window for scheduled doses and providing a formulation of a supplement that did not match the physician's order. The staff involved recognized these incidents as medication errors during interviews and explained the discrepancies between the orders and the actual administration. Record reviews confirmed the physician orders for each resident, including specific instructions regarding timing and formulation of medications. Facility policies required medications to be administered as prescribed, within a one-hour window of the scheduled time, and for staff to verify the correct medication, dosage, time, and route before administration. The documented errors occurred despite these policies, as staff failed to adhere to the established guidelines and physician orders.
Failure to Obtain Informed Consent for Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that informed consent was obtained from a resident's responsible party prior to the use of a physical restraint, specifically a wander guard device, for a resident with severe cognitive impairment and no decision-making capacity. The resident was admitted with diagnoses including hemiplegia following a stroke and aphasia, and was assessed as severely impaired in cognition and unable to make decisions. Despite this, the initial informed consent form for the wander guard indicated the resident was self-responsible and unable to sign, as the facility was unaware of any family at the time. After the facility became aware that the resident had family, there was no documented attempt to obtain written consent from the responsible party, even though the facility's policy required informed consent from the resident or legal representative for the use of physical restraints. The interdisciplinary team attempted to contact the family for a care plan meeting, but the family did not respond or attend. The facility's policies also required that residents or their representatives receive all information regarding risks, benefits, and alternatives to proposed care, including the use of restraints, in advance.
Failure to Maintain and Provide Advance Directive Documentation
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for two residents. For one resident with Alzheimer's disease and hypertension, the facility did not maintain a copy of the resident's advance directive in either the electronic medical record or the physical chart, despite documentation indicating that the resident had executed such a directive. During an interview, a registered nurse confirmed the absence of the advance directive in the records and acknowledged the importance of having this document accessible to honor the resident's healthcare wishes, especially in emergencies. The facility's policy requires that a copy of the advance directive be provided for the resident's clinical record if one exists. For another resident with diagnoses including sepsis, pyelonephritis, and lack of coordination, the facility did not provide written information about the right to prepare an advance directive upon admission, nor could staff locate the required acknowledgement form in the resident's records. Interviews with the Social Service Director and the Director of Nursing confirmed that it is standard procedure to check for an advance directive or provide information on how to formulate one at admission. The facility's policy states that residents must be given written information about their rights under state law to prepare an advance directive prior to or upon admission.
Failure to Notify Responsible Party of One-to-One Monitoring Assignment
Penalty
Summary
The facility failed to inform a resident's responsible party about the initiation of one-to-one monitoring for a resident who was unable to make their own medical decisions. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was assessed as severely cognitively impaired and unable to make decisions. The resident was identified as being at risk for elopement, had previously worn a wander guard, and had removed the device, refusing its reapplication. As a result, staff began one-to-one monitoring to ensure the resident's safety. Despite this significant change in the resident's care, there was no documentation or evidence that the responsible party was notified about the implementation of one-to-one monitoring. Interviews with facility staff, including the Director of Staff Development, a Registered Nurse, and the Director of Nursing, confirmed that the responsible party was not informed of this intervention. The responsible party also stated during an interview that neither she nor the former responsible party had been notified about the one-to-one sitter assignment, learning about the removal of the wander guard only through another family member. Facility policy required that family members or responsible parties be notified of any change in condition, with documentation of the notification in the nurses' notes. The care plan and physician's orders did not reflect the one-to-one sitter intervention, and there was no record of communication to the responsible party regarding this change. This omission constituted a failure to uphold the resident's right to have their representative informed of significant changes in treatment and services.
Failure to Provide Timely SNF ABN Notification for Medicare Coverage Termination
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) in writing to a resident or their responsible party prior to the end of Medicare Part A coverage, as required. Specifically, the SNF ABN form for a resident with severe cognitive impairment and diabetes was not completed to indicate the resident's or representative's choice among the three required options regarding continued care and financial responsibility. The form was signed by the responsible party 19 days after the last covered day, rather than at least 72 hours before coverage ended, as confirmed by both the Accounts Receivables Supervisor and the Director of Nurses during interviews. The facility did not have a policy for beneficiary notices and relied on CMS guidelines, which require timely notification to allow beneficiaries to make informed decisions about their care and financial obligations. The failure to provide the SNF ABN in a timely manner meant the resident or their representative was not properly informed in advance of the end of Medicare coverage and the potential for out-of-pocket costs, nor were they given the opportunity to appeal the decision or determine the course of care before coverage ended.
Failure to Document and Justify Use of Physical Restraint (Wander Guard)
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of physical restraints, specifically in the application and documentation of a wander guard device for a resident. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and severe cognitive impairment. Despite the resident's cognitive status, multiple assessments and monitoring sheets indicated that the resident did not exhibit wandering behavior during their stay, and there were no documented episodes of elopement or attempts to leave the facility. Physician orders were in place for the use of a wander guard, and the resident was monitored hourly, but documentation supporting the ongoing need for the device was inconsistent. The resident's care plan and risk assessments fluctuated, at times indicating risk for elopement and at other times not, without clear rationale documented for these changes. Staff interviews confirmed that the resident refused to wear the wander guard and that there were no observed incidents of wandering or exit-seeking behavior. The facility's policy classified the wander guard as a physical restraint, requiring specific documentation and justification for its use, which was not consistently present in the resident's record. The lack of proper documentation and justification for the use of the wander guard, as required by facility policy, resulted in a deficiency. Staff and leadership acknowledged that the absence of supporting documentation for the restraint could violate the resident's rights and potentially result in psychological harm. The facility's own policies also required that episodes of wandering or exit-seeking behavior be documented in the medical record, along with the interventions used and their effectiveness, which was not done in this case.
Failure to Involve Resident's Representative in Care Plan Meetings
Penalty
Summary
The facility failed to involve a resident's representative or responsible party during the Interdisciplinary Team (IDT) care plan meetings, both quarterly and annually, for one resident who was reviewed under the accidents care area. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was documented as severely cognitively impaired and unable to make decisions. The Minimum Data Set (MDS) and History and Physical (H&P) confirmed the resident's severe cognitive impairment and lack of decision-making capacity. Despite this, the facility's records indicated that the resident did not have any emergency contacts listed at admission, and subsequent care plan conference summaries showed that the responsible party was contacted only once by phone and did not return the call or attend the meeting. Further review and interviews with facility staff, including a Registered Nurse and the Director of Nurses (DON), confirmed that only a single attempt was made to contact the responsible party, with no documented follow-up efforts. The facility's policy and procedure on care planning emphasized the importance of involving the resident's family or legal representative in the development and revision of the care plan and making every effort to schedule meetings at convenient times. However, the lack of adequate follow-up to ensure participation resulted in the resident's representative not being involved in the care planning process.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injection sites were rotated for a resident with type 2 diabetes mellitus, as required by professional standards of practice and the facility's own policies. Record review showed that the resident, who had intact cognitive skills and required assistance with activities of daily living, consistently received insulin injections in the same location—the left lower quadrant of the abdomen—over multiple documented administrations. The Medication Administration Record (MAR) detailed repeated injections at this same site across several dates, without evidence of site rotation. During an interview, a registered nurse confirmed that insulin injection sites should be rotated to prevent injury and acknowledged that repeated injections at the same site can cause pain. Review of the facility's policies on insulin and medication administration further confirmed the requirement for site rotation and adherence to physician orders. The failure to rotate injection sites was identified through both interview and record review, and it was noted that this practice did not align with professional standards or facility policy.
Failure to Communicate and Implement Physician's Dietary Order
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for a resident with multiple diagnoses, including dysphagia, unspecified psychosis, and major depressive disorder. The resident was totally dependent on staff for self-care and had severely impaired cognitive skills. A physician's order was issued to provide a large portion at breakfast, following a recommendation from the registered dietitian to meet the resident's nutritional needs. Despite the physician's order, the kitchen staff did not receive notification of the dietary change. The kitchen supervisor confirmed that the resident's meal tray card did not reflect the large portion order and stated that no communication or ticket had been received from the nursing department regarding the new order. The registered dietitian and the director of nursing both explained that the process requires nursing staff to communicate dietary orders to the kitchen for implementation, but this step was missed in this case. The registered nurse confirmed that the order for a large portion breakfast was not carried out until several weeks after it was written. Facility policy requires that residents receive care and services consistent with their comprehensive assessment and care plan, including dietary needs. The failure to communicate and implement the physician's order resulted in the resident not receiving the prescribed large portion breakfast for an extended period.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with a history of respiratory failure, diabetes mellitus, and obesity. The resident was admitted and later readmitted to the facility, and their Minimum Data Set indicated they had intact cognition but required moderate to total assistance with activities of daily living. The resident was documented as receiving oxygen therapy. During an observation and record review, it was found that the resident's oxygen was set at 1.5 liters per minute (LPM), while the physician's order specified continuous oxygen at 2-4 LPM every shift. The Director of Staff Development confirmed that the oxygen flow rate did not match the physician's order and acknowledged the risk of desaturation. The Director of Nursing also stated that licensed nurses are expected to follow physician orders to ensure the prescribed oxygen flow rate is administered. Facility policy requires medications, including oxygen, to be administered as prescribed.
Failure to Maintain Proper Sanitizing Solution Concentration and Safe Handling of Outside Food
Penalty
Summary
The facility failed to maintain the required concentration of quaternary ammonium sanitizing solution used for cleaning kitchen surfaces. During an observation, a staff member tested the sanitizing solution and found it to be below 100 ppm, which is less than the required 200 ppm as per facility policy. The staff member attempted to replace the solution, but the new batch also tested below 100 ppm. The kitchen supervisor confirmed the low concentration and acknowledged that the solution would not be effective for disinfecting food preparation surfaces. The facility's policy requires the solution to be tested and recorded at least twice daily, and to be replaced if the concentration falls below 200 ppm. Additionally, the facility did not ensure that food items brought from outside for a resident were properly refrigerated or discarded within the required timeframe. A resident with hypertension and type 2 diabetes was observed with leftover food from the previous day on their overbed table. The resident confirmed that the food had been brought by a family member the day before and had not been refrigerated. The Director of Nursing stated that food from outside must be consumed immediately or refrigerated, and that food left at the bedside from the previous day is not safe for consumption. Review of facility policies confirmed that food items brought in for residents are not to be reheated or stored, and must be consumed or discarded promptly. The failure to follow these procedures was observed both in the kitchen's sanitizing practices and in the handling of outside food for a resident, as documented through staff interviews, direct observation, and record review.
Failure to Offer and Document Pneumococcal Vaccine per Facility Policy
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to one of seven sampled residents, as required by its own policy. The resident in question was originally admitted in 2019 and re-admitted in 2025 with diagnoses including acute respiratory failure with hypoxia, sepsis, and diabetes mellitus. Review of the resident's Minimum Data Set indicated moderately impaired cognition and dependence on staff for activities of daily living. During a review of the resident's immunization record, it was found that the last pneumococcal vaccine dose was administered in 2023, but the required consent form for the vaccine was missing, and there was no documentation that the vaccine had been offered as per policy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the resident was due for a second dose of the pneumococcal vaccine and that the facility was responsible for verifying and offering the vaccine to all residents as needed. The facility's policy stated that all residents should be evaluated for pneumococcal vaccination status upon admission and offered the vaccine unless medically contraindicated or already immunized. The failure to offer and document the vaccine for this resident constituted a deficiency in following established procedures.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to administer a COVID-19 booster vaccine to a resident after the resident's representative provided verbal consent for vaccination. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and cerebral infarction, had moderately impaired cognition and was dependent on staff for activities of daily living. Review of the resident's records showed that the last COVID-19 vaccine dose was administered in 2021, and although consent for a booster was obtained in November 2025, there was no physician order or documentation indicating that the vaccine was ordered or given. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) confirmed that the resident had not received the COVID-19 booster despite the consent being documented. The facility's policy required offering COVID-19 vaccinations to all residents per CDC and FDA guidelines unless medically contraindicated, already immunized, or refused. The failure to administer the vaccine after obtaining consent constituted a deficiency in following the facility's vaccination protocol.
Failure to Assess Resident for Self-Administration of Medications by IDT
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in assessing and determining the appropriateness of self-administration of medications for a resident. The resident, who had diagnoses including type 2 diabetes, lumbar spine disc degeneration, hypertension, and a history of lung cancer, was admitted with intact cognition and some need for assistance with activities of daily living. Despite these conditions, the resident was observed organizing and self-administering medications at bedside without an IDT assessment or documented approval for self-administration. The resident reported having self-administered medications since admission and had not participated in an IDT meeting regarding this practice. Facility staff, including an LVN and the DON, confirmed that the resident had been self-administering medications without the required IDT assessment or physician order. The facility's policy requires that the IDT assess each resident's ability to self-administer medications and determine the safety and appropriateness of this practice, with documentation in the care plan. This assessment had not been completed for the resident, and the required procedures for storage, documentation, and ongoing quarterly reassessment were not followed.
Failure to Develop and Implement Care Plan for Spitting Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavior of spitting. The resident, who was admitted with diagnoses including diabetes mellitus, hyperlipidemia, dementia, and dysphagia, was found to have severely impaired cognition and was dependent on staff for most activities of daily living. Despite a long history of spitting, as reported by a Certified Nursing Attendant (CNA), there was no care plan in place to address this behavior. The CNA described providing the resident with a small trash can and reminders to spit into it, but these interventions were not documented in a formal care plan. During interviews and record reviews, the Director of Nursing (DON) confirmed being unaware of the resident's spitting episodes and acknowledged the absence of a care plan for this behavior. The facility's policy requires a comprehensive, resident-centered care plan to be developed for each resident, including measurable objectives and timeframes based on identified needs. However, the care plan for this resident did not address the spitting behavior, resulting in a failure to deliver necessary care and services as outlined in the facility's own procedures.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) and the Individual Count Sheet Record for controlled substances coincided as required by facility policy for one resident. Specifically, a resident with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and who was receiving palliative care, was readmitted and had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety. On a specified date, the MAR indicated that lorazepam was administered to the resident, but there was no corresponding documentation on the Individual Count Sheet Record to confirm this administration. During an interview and record review, the DON confirmed that the MAR showed lorazepam was given, but the Individual Count Sheet Record did not reflect this, which was inconsistent with facility policy. The policy required that when a controlled medication is administered, the licensed nurse must immediately document the administration on both the accountability record and the MAR, including the date, time, amount, and nurse's signature or initials. The failure to document on both records as required was observed and acknowledged by the DON.
Failure to Account for and Secure Discontinued Controlled Medication
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, specifically regarding the handling of a discontinued bottle of lorazepam for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and was receiving palliative care, had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety over a 14-day period. After the medication was discontinued, the bottle with the original prescription number could not be located during a review of medication records and physical inventory. During interviews and record reviews, it was found that the prescription number on the resident's Individual Count Sheet Record did not match the bottle present in the locked medication room. The Director of Nursing (DON) confirmed that the discontinued lorazepam bottle was not received for safekeeping and was not documented as destroyed according to facility policy. The DON also stated that the medication destruction log did not show that the missing bottle had been destroyed, and the bottle was ultimately unaccounted for. Facility policy requires that discontinued controlled substances be brought to the DON, locked for safekeeping, and destroyed in the presence of the DON and a pharmacist, with proper documentation. The failure of licensed nurses to follow these procedures resulted in the loss of accountability for the controlled medication, as the bottle of lorazepam was not properly secured or disposed of after discontinuation.
Failure to Honor Resident Food Preferences and Update Dietary Profile
Penalty
Summary
The facility failed to provide meals that accommodated a resident's food preferences and did not implement its own food preference policy by neglecting to update the resident's dietary profile during the required quarterly review. The resident, who had diagnoses including end stage renal disease, type 2 diabetes mellitus with hyperglycemia, mild protein-calorie malnutrition, and was dependent on renal dialysis, was admitted with specific dietary needs, including a renal/no added salt/consistent carbohydrate diet and a stated dislike for carbohydrates. Despite these documented preferences and dietary orders, the resident was repeatedly served meals containing carbohydrates such as rice, pasta, bread, and cake. The resident reported to staff that these items were consistently provided despite his expressed dislike and concern for their impact on his blood sugar. Observations and interviews confirmed that the kitchen staff did not honor the resident's preferences, and the Director of Dietary Services acknowledged that the resident's dietary profile had not been updated as required during the last quarterly review. The facility's policy required food preferences to be updated at least quarterly or as the resident's needs changed, but this was not done for the resident in question. As a result, the resident's food preferences were not honored, and the facility did not follow its own procedures for updating and documenting dietary preferences.
Failure to Label and Date Prepared Gelatin in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices by not labeling and dating clear storage cups of gelatin according to the facility's policy. During an inspection of the kitchen refrigerator, open food items, specifically clear storage cups containing gelatin, were found without labels or dates. The Dietary Aide confirmed that 11 of these cups were not labeled, and identified them as sugar-free gelatin intended for residents with diabetes. The Director of Dietary Services also confirmed that these items should have been labeled with both the food description and the date of preparation or opening, as per facility policy. A review of the facility's policy and procedure on labeling and dating of foods indicated that all food items in storage, including prepared foods, must be covered, labeled, and dated. The failure to label and date the gelatin cups was a direct violation of this policy. This deficiency had the potential to affect 109 out of 116 residents who receive food from the facility's kitchen.
Non-Functioning Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia following a stroke, a history of falls, and moderate cognitive impairment was found to have a non-functioning call light in their room. During an observation, the call light was tested and found not to be operating. The Registered Nurse Supervisor confirmed the call light was not working and noted it needed to be plugged in to function. After plugging it in, the call light operated properly. The resident's records indicated they had the capacity to understand and make decisions, and the facility's policy required that all residents be shown how to use the call light and demonstrate its use upon admission. The Director of Nursing confirmed that all residents should have a functioning call light to alert staff of their needs. The facility's policy also stated that staff should ensure the call light is within easy reach and operable for residents when they are in bed, a wheelchair, or a chair in the room. The failure to ensure the call light was functioning as required led to the deficiency.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Provide Bed Hold Notice Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed hold notice to a resident and/or the resident's responsible party prior to the resident's transfer to a general acute care hospital. The resident, who had a history of cognitive impairment, dependence on staff for activities of daily living, and multiple medical and psychiatric diagnoses, was transferred under a physician's order for a 72-hour mental health evaluation. Upon review of the resident's records, there was no documented evidence that the resident or their representative was informed about the facility's bed hold policy at the time of transfer. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that no bed hold notice was provided and that there was uncertainty regarding the need for a physician's order for a bed hold. The facility's own policy required written notification to the resident or their representative about the bed hold policy prior to transfer, but this was not followed in this instance.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations was subjected to physical abuse by his roommate. The incident involved the roommate striking the resident multiple times in the face with a fist, resulting in multiple injuries including hematomas and lacerations to the face, nose, lip, chin, and hand. The injuries were severe enough to require transfer to an acute care hospital for evaluation and suturing. The resident was observed with a bloody face and was later readmitted to the facility with visible wounds closed by stitches and ongoing hematomas and bruising. The abused resident had a history of cerebral infarction with hemiplegia and hemiparesis, as well as dementia, and was dependent on staff for most activities of daily living. At the time of the incident, the resident was calling for nursing assistance, which reportedly triggered the roommate's aggressive behavior. The roommate, who also had severely impaired cognition and a history of alcohol dependence, became agitated and physically assaulted the resident. Staff became aware of the incident after hearing screaming and entered the room to find the injured resident and the roommate unable to explain the event. The facility's policy on abuse prevention and resident safety was not effectively implemented, as evidenced by the occurrence of the assault and the resulting harm to the resident. The Director of Nursing confirmed that the incident constituted physical abuse and resulted in actual harm. The report documents the sequence of events, the residents' medical and cognitive conditions, and the immediate observations and assessments following the incident.
Failure to Notify Physician of Behavioral Change After Psychotropic Discontinuation
Penalty
Summary
The facility failed to notify a resident's physician regarding an increase in episodes of yelling after the discontinuation of Seroquel, an antipsychotic medication. The resident in question had a history of dementia, psychosis, hemiplegia, and hemiparesis following a cerebral infarction, and was admitted with severe cognitive impairment and high dependence on staff for daily activities. The physician had discontinued Seroquel, which was previously prescribed for psychotic disorder manifested by yelling. Following the discontinuation of Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record (MAR) over several days. Despite these documented behavioral changes, there was no evidence that the physician was notified of the increased episodes. Interviews with nursing staff confirmed that the episodes were recorded, but the physician was not informed for a psychiatric re-evaluation. A review of the facility's policy indicated that all changes in a resident's condition, including marked changes in mental behavior, should be documented and communicated to the physician and responsible party. However, documentation and interviews confirmed that the required notification and documentation did not occur in this case, resulting in a failure to follow established procedures for change of condition.
Failure to Timely Report Alleged Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to follow its policy and procedures for timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical abuse. An incident occurred in which one resident, who had a history of cerebral infarction with hemiplegia, hemiparesis, and dementia, was struck in the face by a roommate, resulting in facial cuts and a bleeding nose. The resident was noted to have severely impaired cognition and was dependent on staff for most activities of daily living. The incident was documented in the resident's records, and the physician was notified, resulting in the resident being transferred to a hospital for further evaluation and treatment. The facility's internal documentation indicated that the incident occurred in the late afternoon, with the nurse providing first aid and notifying the DON approximately 20 minutes after the event. The DON received the initial call at 5:45 p.m., and the facility's policy required that such allegations involving abuse be reported to the State Survey Agency (SSA) within two hours. However, the actual report to the SSA was sent at 7:52 p.m., which was seven minutes past the required two-hour window. This delay in reporting the alleged abuse resulted in a late notification to the SSA, which in turn delayed an onsite inspection to ensure the safety of other residents. The facility's policy, last reviewed in February 2025, clearly stated the requirement for immediate reporting, but the facility did not meet this standard in this instance.
Failure to Monitor Behavioral Health After Psychotropic Medication Discontinuation
Penalty
Summary
The facility failed to adequately monitor and provide ongoing assessment of a resident's behavioral health needs following the discontinuation of Seroquel, an antipsychotic medication. The resident, who had diagnoses including dementia, psychosis, and hemiplegia/hemiparesis after a cerebral infarction, was admitted with significant cognitive impairment and required extensive assistance with daily activities. After the physician discontinued Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record over several days. However, the required weekly progress notes by licensed nurses were missing for two consecutive weeks during this period, and there was no evidence of consistent monitoring or documentation of the resident's emotional or psychosocial status after the medication change. Interviews with facility staff, including the MDS Coordinator, DON, and an LVN, confirmed that staff were aware of the need to monitor behavioral changes after discontinuing psychotropic medications and to notify the physician if behavioral issues increased. Despite this, the documentation was incomplete, and the facility's own policy required weekly progress notes to reflect the effectiveness of psychotropic medication changes and any side effects or interventions. The lack of ongoing assessment and documentation had the potential to negatively affect the resident's psychosocial well-being.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not providing a duration for a PRN order of trazodone, a medication used to treat depression. The resident, who was admitted with diagnoses including anxiety disorder, dementia, and depression, had a physician order for trazodone to be administered as needed for insomnia. However, the order did not specify a duration, which is a requirement for PRN psychotropic medications to ensure they are limited to 14 days and then reevaluated by a physician. The resident's Medication Administration Record indicated that trazodone was administered multiple times in February without a specified duration, contrary to the facility's policy. During an interview, the Director of Nursing confirmed that the resident was receiving trazodone as needed and acknowledged the oversight in not limiting the PRN order to 14 days. The facility's policy requires that PRN psychotropic medications be limited to a specific duration and used only for clearly documented circumstances, which was not adhered to in this case.
Facility Fails to Maintain Safe Environment Due to Roof and Ceiling Damage
Penalty
Summary
The facility failed to maintain a safe and comfortable environment by not ensuring that the roof was free from cracks, holes, and other damage, which allowed rainwater to penetrate and drip into the space between the roof and ceiling. This resulted in water leaking into multiple areas of the facility, affecting several residents, staff, and visitors. On a rainy day, water leaks were observed in the rooms of several residents, including those with dementia, cerebrovascular disease, multiple sclerosis, and Alzheimer's Disease. The leaks led to room changes for some residents, although not all agreed to move, and buckets were placed to collect the dripping water. In one instance, a resident with dementia and their family member were moved to another room due to water leaking from the ceiling, but they returned to the original room once the leaking stopped. Another resident with multiple sclerosis refused to move despite feeling unsafe, opting to switch beds within the same room. Observations revealed cracks, discoloration, and missing chunks in the ceiling, indicating significant damage. The maintenance supervisor noted several holes near ceiling-mounted ventilation, but was unsure of their purpose. Additionally, the facility failed to maintain the ceiling structure in a shared resident room and the kitchen, where old, repatched areas with cracks and holes were observed. The maintenance supervisor and dietary aide noted that the kitchen ceiling had been repatched years ago, but the cracks and holes had not been addressed. The facility's policies on maintaining a sanitary and homelike environment and conducting regular maintenance inspections were not adhered to, contributing to the unsafe conditions.
Failure to Revise Care Plan for Mechanical Lift Use
Penalty
Summary
The facility failed to revise a care plan to include resident-centered interventions for the use of a mechanical lift for a resident who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and seizures. The resident's Minimum Data Set (MDS) indicated that they required total assistance from staff for various activities of daily living, including transfers. Despite this, the care plan did not specify the need for at least two staff members to assist with the mechanical lift, as required by the facility's policy. During interviews and record reviews, both the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged that the care plan interventions were not marked to indicate the need for two staff members to assist with the mechanical lift. This oversight meant that the care plan was not revised to meet the resident's specific needs for transferring, which is a requirement for person-centered care plans. The facility's policy on mechanical lifts also mandates that two staff members should perform transfers to ensure safety. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to update the care plan with specific interventions for the mechanical lift use indicates a lapse in adhering to this policy. This deficiency had the potential to affect the provision of care for the resident, as the care plan was not individualized to address their specific transfer needs.
Failure to Provide Two-Person Assistance with Mechanical Lift
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) provided the required two-person assistance when using a mechanical lift to transfer a resident from the bed to a wheelchair. This deficiency was observed during a survey where CNA 1 was seen operating the mechanical lift alone, despite the facility's policy requiring two staff members for such transfers. The CNA admitted to transferring the resident alone because no other staff was available at the time. The resident involved in this incident had significant medical conditions, including cerebral infarction, hemiplegia, hemiparesis, and seizures, which necessitated total assistance for transfers. The resident's cognitive skills for daily decision-making were intact, but they required full support for personal hygiene, dressing, and transfers. The CNA acknowledged receiving instructions that the mechanical lift should be used with two-person assistance, especially given the resident's condition. The Director of Staff Development confirmed that the mechanical lift should always be operated by two staff members for safety reasons. The facility's policy, last reviewed in February 2024, clearly stated that the mechanical lift should be used by two staff members to ensure maximum safety. The failure to adhere to this policy posed a potential risk of discomfort and injury to the resident during the transfer.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 2, who was admitted with diagnoses including dysphagia and dementia. The resident's Minimum Data Set indicated severe cognitive impairment, and the care plan specifically required the call light to be within reach to prevent falls or physical injury. However, during an observation, the call light was found hanging off the overhead lamp, out of the resident's reach. A Registered Nurse confirmed that the call light should be accessible to the resident to allow them to signal for assistance, such as needing to use the toilet or requiring a change. The nurse acknowledged that the resident could suffer from skin breakdown if left soiled due to the inability to call for help. The facility's policy on call light usage, last reviewed earlier in the year, emphasized the importance of positioning the call light within the resident's reach to meet their needs promptly.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident abuse to the State Survey Agency (SSA) within the required timeframe. The incident involved a resident with schizophrenia and anxiety, who was reportedly locked in a family room by the Director of Nursing (DON) after the resident was yelling. This incident was witnessed by a Certified Nursing Assistant (CNA). The Social Services Assistant (SSA) was informed of the incident by the CNA but did not report it immediately to the Administrator (ADM) as required by the facility's policy. The SSA believed the incident constituted abuse and should be reported right away but did not act because the ADM was busy and the SSA was not a direct witness to the event. The facility's policy mandates that any alleged abuse must be reported to the Department of Public Health within two hours. However, the SSA delayed notifying the ADM, which in turn delayed the reporting to the appropriate authorities. The ADM confirmed that the SSA and the unnamed CNA should have reported the incident immediately to ensure timely reporting to the Department of Public Health. The facility's policy clearly outlines the responsibility of mandated reporters to report any suspected abuse immediately, but this protocol was not followed in this case.
Failure to Label Urinal Bottles for Infection Control
Penalty
Summary
The facility failed to implement proper infection control practices by not labeling a resident's urinal bottles with the resident's name and room number. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who confirmed the presence of two unlabeled urinal bottles belonging to a resident. One urinal bottle was found hanging on the right upper side of the resident's bed rail, while the other was on top of the resident's drawer. The LVN acknowledged that the facility staff should have labeled the urinal bottles to prevent the potential spread of infection and cross-contamination among staff and other residents. The resident involved in this deficiency had been admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and hypertension. The resident's Minimum Data Set (MDS) indicated that their cognition was intact, and they required moderate assistance with personal hygiene and were dependent on staff for toileting hygiene and bathing. The facility's policy on Resident Dignity/Resident Rights and Infection Control Guidelines emphasized the importance of labeling personal items to promote good infection control practices, which was not adhered to in this instance.
Failure to Inform Resident of Laboratory Results
Penalty
Summary
The facility failed to protect the rights of a resident by not ensuring that the resident and their responsible party were informed of a laboratory result. The resident, who was admitted with diagnoses including cerebral infarction, hypertension, and hypothyroidism, had intact cognition and was dependent on staff for various personal care activities. A Thyroid Stimulating Hormone (TSH) test was conducted on the resident without a physician's order, and the result, which was significantly outside the normal range, was not communicated to the resident or their responsible party. During an interview and record review, a registered nurse acknowledged that there was no physician order for the TSH test conducted, which should have been obtained prior to the test. The nurse also stated that the resident and their responsible party should have been informed of the test results as it is their right to be informed about the resident's care and treatment. The facility's policy on resident rights, which guarantees the right to be informed and participate in care planning, was not adhered to in this instance.
Failure to Obtain Physician Order for TSH Test
Penalty
Summary
The facility failed to obtain a physician order for a Thyroid Stimulating Hormone (TSH) test for a resident, identified as Resident 2, which was conducted on 8/7/2024. Resident 2 was admitted to the facility with diagnoses including cerebral infarction, hypertension, and hypothyroidism. The Minimum Data Set (MDS) indicated that Resident 2 had intact cognition and was dependent on staff for various personal care activities. Despite the absence of a physician order, the TSH test was performed, and the results showed a significantly elevated TSH level of 48.12 ulU/ml, compared to the normal reference range of 0.45 to 5.33 ulU/ml. During an interview and record review, Registered Nurse 2 confirmed that there was no physician order for the TSH test conducted on 8/7/2024. The facility's policy, titled 'Lab and Diagnostic Test Results-Clinical Protocol,' mandates that a physician must identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The failure to obtain a physician order before conducting the TSH test was acknowledged by RN 2, who stated that this oversight could affect the resident's plan of care and posed an increased risk for injury and harm to Resident 2.
Failure to Monitor and Address IV Site Pain
Penalty
Summary
Facility staff, specifically RN 3, failed to monitor and provide appropriate care for a peripheral intravenous (IV) line for a resident, identified as Resident 65. On 10/6/2024, Resident 65 complained of pain at the IV site on the left forearm, but RN 3 did not check the patency of the IV line or address the resident's complaint of pain. Despite the visible presence of blood around the IV tubing, RN 3 continued to administer the antibiotic Zosyn through the IV line without verifying its placement or checking for infiltration. Resident 65, who was admitted to the facility on 9/4/2024, had a medical history that included chronic obstructive pulmonary disease, atrial fibrillation, transient ischemic attack, and cerebral infarction. The resident required substantial assistance with daily activities and had an IV line inserted on 10/3/2024 for the administration of antibiotics to treat a wound infection. The IV line was later found to be infiltrated, causing pain and requiring removal on 10/7/2024 by RN 4. Interviews with Resident 65, their wife, and facility staff revealed that RN 3 did not take appropriate action when informed of the pain and visible issues with the IV site. The Director of Nursing confirmed that licensed nurses are expected to address any reported pain immediately. Additionally, the Medical Records Assistant indicated that there was no existing policy regarding IV medication administration and peripheral IVs, which may have contributed to the oversight.
Failure to Properly Set LALM and Measure Heel Ulcers
Penalty
Summary
The facility failed to ensure the proper setting of a low air loss mattress (LALM) for a resident, which could potentially increase the risk of skin breakdown. The resident, who was admitted with diagnoses including hypertension and osteoarthritis, was observed using a LALM set for a weight range of 320-400 pounds, despite weighing only 150 pounds. There was no physician's order for the use of the LALM, and the Director of Nursing (DON) acknowledged that an incorrect setting could lead to skin breakdown and infection. Additionally, the facility did not measure a resident's deep tissue injury (DTI) pressure ulcers on the heels for approximately six weeks. The resident, who had diagnoses including diabetes mellitus and Alzheimer's disease, had an order to cleanse and dress the heel wounds daily, but the facility failed to document the length, width, or depth of the wounds. The DON and a registered nurse confirmed the importance of documenting wound measurements to assess healing and adjust treatment plans accordingly. The facility's policy required weekly documentation of pressure ulcer characteristics, which was not followed in this case.
Failure to Document Pain Assessments for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 63, was assessed for pain per shift as ordered by the physician. Resident 63, who was originally admitted on 1/12/2022 and readmitted on 6/5/2023, had a complex medical history including meningitis, intraspinal abscess, granuloma, paraplegia, and perineural cyst. The resident had intact cognition and required moderate assistance for most activities of daily living. The physician's orders included administering hydrocodone-acetaminophen for severe pain and assessing pain every shift using a pain rating scale. However, the Medication Administration Records (MARs) for July and August 2024 showed multiple instances where pain assessments were not documented, indicating a failure to comply with the physician's orders. During interviews, Registered Nurse 1 acknowledged that pain assessments might have been missed but noted that Resident 63 would inform staff when in pain. The Director of Nursing emphasized the importance of completing all pain assessments to evaluate the resident's pain and the effectiveness of pain medications. The facility's policy on Pain Assessment and Management, reviewed in February 2024, required that residents be provided optimal comfort through a mutually established pain control plan and that pain assessments and documentation be completed as ordered by the physician. The lack of documented pain assessments had the potential for Resident 63 to experience undetected pain.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that licensed nurses monitored for side effects while a resident was receiving apixaban, an anticoagulant medication. This oversight was identified for one of the three sampled residents, who was admitted with diagnoses including cerebral infarction and hemiplegia. The resident's physician's orders required monitoring for side effects such as gum bleeding, nose bleeding, unusual bruising, and other symptoms each shift, with instructions to notify the doctor if any symptoms were present. However, the Medication Administration Records (MAR) for July and August 2024 showed multiple shifts where the resident was not monitored for these side effects. Interviews with Registered Nurse 1 and the Director of Nursing confirmed that the resident should have been monitored for side effects of apixaban, including signs of bleeding and excessive bruising. The facility's policy on anticoagulation use, last reviewed in February 2024, also required nursing staff to monitor for signs of bleeding and report them to the physician. The failure to monitor and document these side effects as per the physician's orders and facility policy constituted a deficiency in the resident's care.
Failure to Monitor Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that licensed nurses monitored a resident for changes in behavior and side effects while receiving Seroquel, an antipsychotic medication. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and generalized anxiety disorder, was prescribed Seroquel to manage schizophrenia manifested by agitation. The physician's orders required monitoring for changes in behavior, Parkinsonism symptoms, akathisia, tardive dyskinesia, and cognitive impairment each shift. However, the Medication Administration Records (MAR) revealed that the resident was not monitored for these conditions on multiple occasions across July and August. Specifically, there were several shifts where monitoring for changes in behavior, Parkinsonism symptoms, akathisia, tardive dyskinesia, and cognitive impairment was not documented. This lack of monitoring was confirmed during an interview with a registered nurse, who acknowledged that the absence of documentation could hinder the evaluation of the medication's effectiveness and the detection of side effects. The Director of Nursing also confirmed that the resident should have been monitored for behavior and side effects to effectively communicate with the physician and assess the need for a dose reduction. The facility's policy on psychotropic medication indicated that nursing staff should monitor drug use daily for adverse effects, but this was not adhered to in the case of the resident receiving Seroquel.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for five out of seven sampled residents, which included residents with indwelling devices such as catheters, G-Tubes, and wounds. These residents were not placed on EBP, and there were no EBP signs posted on their doors or walls to indicate the need for such precautions. The Infection Preventionist (IP) acknowledged awareness of EBP since July 2024 and confirmed that these residents should have been on EBP to prevent the potential spread of infection. The lack of EBP signs and adherence to EBP protocols was observed during room inspections and interviews with staff, who admitted to not following the required precautions. Additionally, the facility's kitchen staff failed to adhere to infection control policies. The Dietary Manager was observed handling food without wearing a hairnet, contrary to the facility's policy, which mandates hairnets to prevent hair debris from contaminating food. Furthermore, a cook was seen wearing dangly jewelry while handling food, which is against the dress code policy that prohibits excessive jewelry to avoid cross-contamination. Both staff members acknowledged their lapses and the potential risks associated with not following the dress code. The facility's policies and procedures for EBP and kitchen dress code were reviewed, revealing that the guidelines were in place but not followed by the staff. The failure to implement these precautions and adhere to policies posed a risk of spreading infections among residents and potential foodborne illnesses due to cross-contamination in the kitchen.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure privacy for a resident during a medical procedure, which violated the resident's right to privacy. This incident involved a Licensed Vocational Nurse (LVN1) who did not close the privacy curtain while performing a blood sugar level check and administering oral medications to a resident. The resident, who was admitted with diagnoses including difficulty in walking and type 2 diabetes mellitus, was within sight of their roommate and visible from the hallway during the procedure. The resident's Minimum Data Set (MDS) indicated that their cognitive skills for daily decision-making were intact, and they required substantial assistance with personal care tasks. During an observation and interview, LVN1 acknowledged the failure to close the privacy curtain and admitted that this oversight violated the resident's rights to dignity and privacy. The facility's policy on dignity and privacy, dated 11/28/2018, emphasizes the importance of maintaining or enhancing each resident's dignity and respect.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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