Sunnyside Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22617 S. Vermont Ave, Torrance, California 90502
- CMS Provider Number
- 056488
- Inspections on file
- 69
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Sunnyside Nursing Center during CMS and state inspections, most recent first.
Two residents experienced changes in condition that led to physician orders for a respiratory panel and a BMP, but staff did not ensure the ordered blood tests were collected and did not document any follow-up or physician notification when the tests were not performed. One resident with COPD and other chronic conditions had a new cough and loss of appetite, prompting an order for a respiratory panel that was never carried out. Another resident with heart failure, hypothyroidism, and AFib had episodes of diarrhea, nausea, and vomiting, leading to an order for a BMP that was not collected, as shown by the missing phlebotomist signature on the lab log. The IPN, DON, and ADON confirmed there was no documentation of lab follow-up or physician notification, and the facility’s lab/diagnostic test policy lacked procedures for tracking collection or notifying the physician when tests were not completed.
A resident with a history of fractures and normal cognitive function was roughly handled by a CNA during personal care, despite expressing a preference for shower timing and warning about a prior injury. The CNA, appearing rushed and overwhelmed, squeezed the resident's left hand hard while assisting with a gown, resulting in a purplish discoloration and emotional distress. The incident was corroborated by staff interviews and facility policy requiring respectful treatment was not followed.
A resident with cognitive and medical impairments was reportedly handled roughly by a male CNA during a night shift. The responsible party informed an LVN, but the LVN did not immediately report the allegation to the RN Supervisor or abuse coordinator as required. Staff interviews confirmed the delay, and the administrator only reported the incident to authorities several hours after learning of it, exceeding the required two-hour reporting window.
A nurse failed to review and clarify conflicting hospital discharge instructions for a resident with end-stage renal disease, resulting in the administration of Baclofen despite explicit instructions not to use it. The resident developed acute toxic encephalopathy and required hospital transfer and hemodialysis. The error occurred because the nurse did not follow facility policy to verify orders with the physician, leading to an Immediate Jeopardy situation.
A resident who required assistance with ADLs and expressed a strong preference for showers over bed baths was not consistently provided showers as requested. Documentation showed limited showers, multiple refusals of bed baths, and several undocumented shifts. Staff interviews confirmed the resident's preferences were known but not always accommodated, contrary to facility policy on respecting resident choices.
A resident with left side hemiplegia and a high fall risk was admitted and assessed using the Morse Fall Scale and interdisciplinary team review. Despite being identified as high risk for falls, the care plan did not include the facility's Fall Management Program interventions, such as a low bed, fall pad, colored wristband, or star magnet, as required by facility policy. Instead, only general fall prevention measures were documented, resulting in incomplete care planning for the resident.
A resident was administered Baclofen despite conflicting hospital discharge instructions and without physician clarification, resulting in adverse health effects and hospital transfer. The facility did not file an incident report or conduct a QAPI meeting to address the error, contrary to its policies.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
The facility did not consistently implement required interventions to manage and prevent pressure ulcers, resulting in inadequate care for residents with or at risk for pressure ulcers.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
A resident with significant mobility limitations and no initial sacrococcyx wounds developed a severe, facility-acquired pressure injury after staff failed to consistently implement physician orders and facility policy for turning, repositioning, and incontinence checks. Documentation showed repeated missed interventions, lack of care plan updates, and no record of resident refusals, resulting in the progression of a pressure ulcer to stage 4 with infection and hospitalization.
A resident with significant mobility limitations and no initial sacrococcyx pressure injury developed a worsening wound after spending extended periods in a wheelchair without appropriate offloading interventions. Staff and family reported the absence of consistent pressure relief measures or care plan updates to address the resident's needs, resulting in the progression of a pressure injury from stage two to unstageable. The DON confirmed that the care plan lacked specific interventions for pressure relief while the resident was in the wheelchair.
A resident with impaired mobility and muscle weakness experienced a 30-day delay in receiving ordered PT and OT services due to the rehabilitation department's failure to follow up on therapy authorization. Despite facility policies assigning responsibility for timely tracking and implementation of therapy orders, the delay occurred, resulting in a significant gap before therapy was initiated.
A restorative nurse assistant failed to remove PPE and perform hand hygiene before exiting the room of a resident on Enhanced Barrier Precautions due to dialysis access and recent amputation. The staff member exited the room wearing gloves and a gown to retrieve an oxygen tank, contrary to facility policy and posted instructions, and later acknowledged the error during an interview. Facility leadership confirmed that PPE should be removed and hand hygiene performed before leaving such rooms to prevent infection transmission.
A resident with a history of anxiety and cognitive decline accessed unsecured rehab equipment without staff knowledge and used a dowel to physically assault two other residents, resulting in injuries including a sacral fracture. The rehab room door was not locked when unsupervised, and equipment was left accessible, contrary to facility policy requiring individualized safety interventions and supervision. Staff were unaware of the resident's access to the equipment until after the incidents occurred.
A resident accessed an unsecured rehabilitation dowel and used it to physically assault two other residents, resulting in one sustaining a sacral fracture and requiring hospital transfer. The rehabilitation room and its equipment were not consistently secured or supervised, and staff did not follow facility policy to prevent or address abuse.
A resident's responsible party reported multiple complaints about inadequate ADL care, which were not formally logged or investigated by the facility. The resident, with severe cognitive impairment and dependence on a ventilator, was found in soiled briefs and ungroomed. Despite discussions with an RN, the grievance process was not initiated, leading to a lack of formal investigation and follow-up, potentially delaying necessary care.
A facility failed to conduct timely IDT meetings for a resident with chronic respiratory failure and ventilator dependence, excluding the resident's Responsible Party (RP) from the process. Despite multiple hospitalizations and severe cognitive impairment, the last IDT meeting involving the RP was held months prior, leaving the RP without the opportunity to discuss concerns about the resident's care, including pressure ulcer management. The facility's policies require IDT involvement with the resident and family to develop and update care plans, especially after hospital readmissions.
A resident with chronic conditions experienced an incident where a water bottle fell on their foot, causing pain. The facility failed to document a Change of Condition, notify the physician and family, and conduct necessary assessments and monitoring. Despite a treatment plan for the resident's worsening toe condition, weekly assessments were not performed, revealing deficiencies in care and documentation.
A resident in a persistent vegetative state developed a Stage II pressure injury that progressed to Stage IV due to the facility's failure to provide consistent treatment and monitoring. The facility did not follow physician orders, lacked timely wound assessments, and delayed nutritional consultations, contributing to the deterioration of the pressure injury.
A resident at high risk for falls was left unsupervised in the bathroom by a CNA, contrary to the facility's fall prevention policy. The resident, who required assistance with ambulation and used a front wheel walker, attempted to walk back to bed alone and fell, resulting in multiple fractures. Staff interviews confirmed the resident's need for supervision, and the fall was deemed preventable.
The facility failed to properly store and label food, with Lysol bleach cleaner found in the dry food storage area, an unclean ice machine drain, and missing freezer temperature logs. Staff acknowledged the risks of contamination and serving expired food, violating facility policies.
Two residents experienced delayed care due to the facility's failure to respond to call lights promptly. One resident, with intact cognition and multiple health issues, was left in severe pain for over 25 minutes despite pressing the call light and calling for help. Another resident, with dementia and mobility issues, had the call light clipped out of reach, increasing the risk of falls. Staff acknowledged the importance of timely response, as per facility policy, but failed to meet these standards.
A facility experienced a 34.48% medication error rate due to improper administration and timing of medications for four residents. A resident did not receive a full dose of Amlodipine via GT, while another's BP was not reassessed before medication administration. Two residents received their medications significantly late, contrary to facility policy. These deficiencies highlight issues in medication administration practices.
A resident with a history of seizures and other conditions experienced significant medication errors due to late administration of prescribed medications, including Phenytoin, Phenobarbital, and Heparin. The medications were given several hours late on multiple occasions, contrary to the physician's orders. The LVN responsible did not inform the physician before administering the medications late, and the RN confirmed that such delays could lead to potential overdosing.
The facility failed to follow infection control practices, including not changing and labeling oxygen and feeding bags, improper PPE use by staff, and inadequate cleaning procedures. A visitor also did not wear PPE in a resident's room under contact isolation for Candida Auris.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over the resident while feeding her, contrary to the facility's policy of providing a dignified dining experience. The resident, with severe cognitive impairments, required substantial assistance with eating. Staff interviews confirmed that proper procedure involves sitting at eye level to ensure comfort and prevent aspiration.
A facility failed to reassess the PASARR for a resident diagnosed with mental illness and placed on antipsychotic medication. The resident, with diagnoses including psychosis and anxiety disorder, was not reassessed for PASARR Level 1 after being placed on antipsychotic medication. The oversight was acknowledged by the Director of Medical Records and the Minimum Data Set Coordinator, who confirmed that the facility missed updating the PASARR Screening, potentially delaying necessary care and services.
Two residents in the facility experienced deficiencies in medication administration. One resident did not receive the full dose of Amlodipine due to improper mixing and administration via a gastrostomy tube. Another resident's blood pressure was not reassessed before administering medications with specific parameters, leading to potential risks. The facility's policies for medication administration and vital sign monitoring were not followed, impacting the care provided to these residents.
The facility failed to secure medication carts, leading to potential unauthorized access, and improperly stored home medications without a physician's order. Additionally, an opened medication lacked proper labeling, risking the use of expired medication. These deficiencies highlight lapses in medication security and adherence to facility policies.
A resident with diabetes and pulmonary hypertension did not have her food preferences honored, as the facility frequently ran out of requested items like bacon and cream of wheat. Despite documented preferences and a controlled carbohydrate diet, the resident received alternative foods, leading to dissatisfaction. Staff interviews confirmed that popular items often ran out, and the Dietary Supervisor admitted to not regularly engaging with residents unless complaints were made.
The facility's QAPI committee failed to establish a system for medication management, fall prevention, and pressure ulcer monitoring, resulting in medication errors, fall-related injuries, and inadequate pressure injury documentation. The Administrator could not provide evidence of preventive measures, despite the facility's policy indicating a need for a systematic process to improve resident care and safety.
A facility failed to follow its antibiotic stewardship program by administering antibiotics to a resident without meeting Loeb's or McGeer's criteria. The resident, with conditions like hemiplegia and neuromuscular bladder dysfunction, was given Ampicillin for a UTI without proper justification. The Director of QA confirmed the oversight, and the CCO noted potential risks of unnecessary antibiotic use.
A facility failed to offer, educate, and document influenza vaccinations for a resident with impaired cognition and dependency on care, as per its policy. Despite being eligible, there was no record of the vaccine being offered or declined. The Director of QA and CCO emphasized the importance of vaccinations to prevent infections, but the facility's procedures were not followed, resulting in a deficiency.
The facility failed to offer, educate, and document COVID-19 vaccinations for two residents, contrary to its policy. One resident with hemiplegia and another with chronic respiratory failure were eligible for the 2024-2025 vaccine, but there was no documentation of the vaccine being offered, education provided, or refusal recorded. The Director of QA confirmed the oversight, highlighting the importance of vaccination to prevent infection spread.
A resident with mental health diagnoses was left exposed during personal care when a CNA failed to close the privacy curtain after a shower. The CNA left the room to get towels, leaving the resident half-naked and visible to others, violating the facility's policy on maintaining resident privacy.
The facility was found to have 83 rooms that did not meet the required 80 square feet per resident in multiple resident bedrooms, as identified in the Client Accommodations Analysis Form. Despite this deficiency, no immediate concerns with privacy, safety, or care were observed during the survey, and the Administrator reported no resident complaints. The facility intends to request a room waiver.
A facility failed to implement resident-centered care plans for a resident with a craniectomy and pressure ulcers. The resident's responsible party was not updated on wound care treatments as agreed, and the resident was not wearing a helmet during a hospital transfer, violating the care plan. The facility did not adhere to its policies requiring regular wound assessments and family notifications.
A resident with cognitive impairments and at risk for pressure ulcers was incorrectly assessed with a Stage 3 pressure ulcer instead of the correct Stage 4, violating NPUAP guidelines. This misclassification, identified by the Quality Assurance Nurse and confirmed by the DON, could lead to miscommunication and delays in care. The facility's policy requires accurate wound staging to ensure proper treatment.
A resident with mild cognitive impairment and diabetes mellitus eloped from the facility due to inadequate supervision and lack of a care plan addressing his wandering risk. Staff were not informed of the resident's risk status, and there was no system in place to monitor his whereabouts effectively. The resident's absence went unnoticed for over two hours, highlighting a significant deficiency in the facility's monitoring and communication protocols.
A facility failed to develop and implement a care plan for a resident with severe cognitive impairment who has a history of banging her arms against bed side rails. The resident was observed with a bruise on her forearm, and no interventions were in place to prevent further injury. The resident's responsible party was not informed of any new interventions, and the care plan lacked measures to address the resident's behavior. The facility's policies on care planning were not followed, placing the resident at risk for further injury.
A facility failed to ensure proper infection control practices for residents on contact isolation due to C. diff infections. Staff were observed not wearing required PPE and using hand sanitizer instead of washing hands with soap and water, contrary to facility policy. This breach in protocol was confirmed through staff interviews and policy reviews.
A resident with diabetes experienced multiple episodes of watery stool and high blood sugar levels. The facility failed to notify the physician promptly and did not administer insulin as ordered. This led to the resident's condition worsening, requiring transfer to a hospital for further management.
The facility failed to conduct N95 mask fit testing for six staff members, risking improper mask use and exposure to infections. Additionally, a CNA improperly handled soiled linens by swinging a bag of dirty bibs, risking contamination. Both actions violated infection prevention protocols.
A resident with multiple health conditions was prescribed Amoxicillin for bacteremia, but the LTC facility failed to monitor its use as part of their antibiotic stewardship program. This oversight resulted in the resident developing a Clostridium difficile infection, as confirmed by a stool exam. Interviews with staff revealed a lack of documentation and surveillance data regarding the antibiotic use, contrary to the facility's policy on antibiotic stewardship.
Two CNAs failed to perform hand hygiene between resident care and when entering and exiting resident rooms, as observed during a survey. CNA 3 admitted to rushing and not following proper procedures, while CNA 1 acknowledged carelessness. The facility's policies emphasize the importance of hand hygiene to prevent infection spread, as reiterated by the Infection Prevention Nurse.
A facility failed to provide care consistent with professional standards for a resident with a PICC line. The resident's PICC line was found on the floor, and the nurse did not notify the physician or monitor the site for complications as required. The Unit Manager confirmed there were no orders to discontinue the PICC line and no documentation of physician notification or site monitoring after removal.
Failure to Collect Ordered Labs and Notify Physician When Tests Not Performed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were collected in a timely manner and that physicians were notified when those tests were not performed for two residents. For one resident admitted with COPD, HTN, and hyperlipidemia, with moderate cognitive impairment but largely independent in ADLs, a respiratory infection screener documented a new or increased cough and loss of appetite. A change in condition evaluation on the same day showed a new physician order for a respiratory panel. However, the respiratory panel order dated that day was not carried out, and there was no follow-up to ensure the specimen was collected. For the second resident, admitted with hypertensive heart disease with heart failure, hypothyroidism, atrial fibrillation, and a history of COVID-19, and documented as having severe cognitive impairment and needing extensive assistance with ADLs, a change in condition note recorded two episodes of diarrhea, with the physician and responsible party notified. Later that day, another change in condition note documented nausea and two episodes of vomiting. A physician order was then written for a one-time morning BMP. Review of the laboratory log showed no phlebotomist signature for this BMP order, indicating the specimen was not collected as ordered. Record reviews and interviews with the Infection Prevention Nurse showed that for both residents there was no documentation in change in condition follow-up notes or progress notes that the ordered labs were followed up for collection or that the physician was notified when the respiratory panel and BMP were not obtained. The IPN, DON, and ADON each stated the importance of collecting these labs and notifying the physician when they were not collected, but the facility’s written policy on lab and diagnostic test results did not include procedures for following up on whether tests were collected or sent to the lab, nor did it specify procedures for notifying the physician when a lab or diagnostic test was not collected or performed.
Failure to Ensure Resident Dignity and Safe Handling During Personal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to treat a resident with dignity and respect during personal care, resulting in rough handling. The resident, who had a history of multiple rib fractures and a previous left arm injury from a car accident, required full assistance with toileting and personal hygiene. On the day of the incident, the CNA appeared rushed and in a bad mood, reportedly due to working a double shift. The resident expressed a preference for showering later in the day, but the CNA insisted on providing a morning shower and responded curtly when informed of the resident's preference. After the shower, the CNA left the resident in a wheelchair for about 30 minutes and did not return to clean the bedside area. Later that evening, while assisting the resident with putting on a gown, the CNA squeezed the resident's left hand very hard, despite being told to be careful due to the resident's prior injury. The resident reported feeling that the CNA was handling her too roughly and expressed concern during care, but the CNA did not respond and continued with the task. The following day, the resident noticed a purplish discoloration on her left thumb and reported it to a licensed vocational nurse (LVN), stating that the injury likely occurred when the CNA squeezed her hand. Interviews with staff and another resident corroborated the account of rough handling and emotional distress. The LVN and unit director of nursing (UDON) observed the discoloration and found the resident's report credible, noting that the injury was consistent with the described incident. Facility policy requires all residents to be treated with kindness, respect, and dignity, which was not upheld in this case.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting a suspected abuse incident to the State Survey Agency within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and multiple medical conditions, including acute kidney failure and chronic heart failure, was reportedly handled roughly by a male CNA during a night shift. The resident's responsible party informed an LVN of the incident, but the LVN did not notify the RN Supervisor or the abuse coordinator as required by facility policy and instead advised the responsible party to follow up with management on the next business day. Multiple staff interviews confirmed that the allegation of rough handling was communicated to the LVN on the day it was reported, but the LVN did not escalate the report immediately. Other staff, including another CNA and RN, stated that such allegations should be reported to the abuse coordinator and investigated without delay, regardless of the time or day. The facility's policy clearly states that all allegations of abuse, neglect, or mistreatment must be reported immediately, but not later than two hours after the allegation is made, to the appropriate authorities. The delay in reporting resulted in the abuse allegation not being communicated to the State Survey Agency, ombudsman, and law enforcement within the required timeframe. The administrator only became aware of the incident the following day and subsequently reported it approximately six hours after being informed. This failure to follow established reporting procedures placed residents at risk for potential continued abuse and delayed investigation.
Failure to Reconcile Discharge Orders Leads to Baclofen Toxicity and Immediate Jeopardy
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly review and reconcile conflicting hospital discharge instructions for a resident who had end-stage renal disease and was dependent on hemodialysis. The discharge documents from the general acute care hospital contained contradictory orders: one stated that Baclofen should not be used due to causing confusion, while another listed Baclofen as a medication to continue. The nurse did not review the entire set of discharge instructions for accuracy, nor did she clarify the conflicting orders with the resident's physician before transcribing and administering Baclofen. As a result, the nurse administered multiple doses of Baclofen to the resident without physician verification, contrary to the facility's policy requiring such verification for hospital transfer orders. There was no documentation indicating that the nurse contacted the attending physician to resolve the discrepancy. The resident subsequently experienced shortness of breath, elevated blood pressure, generalized weakness, and increased confusion, which led to a change of condition and transfer to the hospital. At the hospital, the resident was diagnosed with acute toxic encephalopathy due to Baclofen toxicity and required hemodialysis. Interviews with facility staff, the resident's family, and medical professionals confirmed that the medication error was due to the failure to reconcile and verify the discharge orders, and that the facility's policy and standard admission process were not followed. The incident resulted in an Immediate Jeopardy situation due to the serious harm caused to the resident.
Removal Plan
- The admitting nurse verified the admissions orders with the attending physician.
- A medication error report for Baclofen was completed and reported to the attending physician and Resident 10's family.
- The Interim Chief Clinical Officer (CCO)/Designee provided a 1:1 in-service training to RN 1 on reviewing discharge orders, reconciling and verifying orders with attending physicians prior to carrying out the orders, and the facility's policy requiring verification of GACH orders with the attending physician before medications are transcribed for administration.
- A random audit of all in-house patients was completed by the Health Information Manager (HIM) and the Interim CCO/designee.
- All residents receiving Baclofen were identified and reviewed.
- A random audit of all newly admitted residents was conducted by the HIM and Interim CCO/designee.
- All identified residents' physician orders were reviewed and reconciled with their attending physicians.
- The Director of Staff Development (DSD)/Clinical Trainer provided re-training to licensed nurses on entering orders into the Electronic Treatment Administration Record (eMAR/eTAR) prior to/pending confirmation, reconciliation, and verification of orders.
- Licensed nurses on leave, vacation, out sick, or newly hired will be educated prior to the start of their shift.
- The DSD and Clinical Trainer conducted in-service training for licensed nursing staff on the facility's policy requiring verification of GACH orders with the attending physician before medications are transcribed for administration.
- Training will continue until all licensed nursing staff have attended.
- Nurses on leave, vacation, out sick, or newly hired will be educated prior to the start of their shift.
- A root cause analysis (RCA) was conducted, revealing multiple system-level factors contributing to the medication reconciliation error, including knowledge gaps, inconsistent policy application, lack of structured admission process, and limited leadership oversight.
- A multidisciplinary team (Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, Regulatory Compliance Nurse) was assigned specific roles to monitor, oversee, and implement corrective actions, conduct audits, provide ongoing training, update policies, and ensure compliance and quality improvement.
Failure to Honor Resident's Bathing Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's expressed preference for showers over bed baths. The resident, who was admitted following a left leg below-the-knee amputation and required assistance with activities of daily living, was documented as being able to make reasonable and consistent decisions. The Minimum Data Set indicated that it was very important for the resident to choose between a bed bath or a shower. However, documentation showed that during a specified period, the resident received only two showers, refused a bath six times, and had fifteen shifts with no documentation of bathing care provided. The resident reported that, despite requesting showers, he was often given bed baths instead, and sometimes refused care when staff insisted on a bed bath. After a COVID-19 diagnosis, the resident refused a shower due to not feeling well, but also stated that his requests for showers were not accommodated during his recovery. Interviews with staff confirmed that the resident was particular about his care, especially regarding showers, and that residents should be able to make decisions about their care. Facility leadership acknowledged the importance of honoring resident preferences to ensure comfort and satisfaction. The facility's policy on dignity and quality of life emphasized providing care in a manner that respects resident rights and preferences, but this was not consistently followed in the resident's case.
Failure to Implement Fall Management Program in High-Risk Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included a Fall Management Program for a resident assessed as high risk for falls. The resident, who had a history of cerebral infarction resulting in left side hemiplegia and required assistance with activities of daily living, was identified as high risk for falls based on the Morse Fall Scale and interdisciplinary team assessments. Despite these findings, the care plan only included general interventions such as encouraging the resident to use the call light and attempting to anticipate needs, without incorporating the facility's established Fall Management Program. Interviews with facility leadership confirmed that the Falling Star Program, which includes specific interventions like a low bed, fall pad, colored wristband, and star magnet, should have been included in the care plan for residents at high risk for falls. Review of facility policies indicated that such interventions are required for residents with high fall risk, but documentation showed these were not implemented for the resident in question. This omission resulted in the resident's care needs not being thoroughly addressed.
Failure to Implement QAPI Following Medication Error
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) plan after being made aware of a medication error involving a resident who was admitted from a general acute care hospital. The registered nurse did not thoroughly review or clarify conflicting discharge instructions regarding the administration of Baclofen, a medication known to cause confusion, before transcribing and administering it. Specifically, the nurse did not verify the hospital's orders with the attending physician, despite discrepancies in the discharge instructions—one indicating Baclofen should not be used due to confusion, and another listing it as a medication to continue. As a result, the resident received multiple doses of Baclofen without proper clarification. This error led to the resident experiencing shortness of breath, elevated blood pressure, generalized weakness, and increased confusion, ultimately resulting in a transfer back to the hospital where the resident was diagnosed with acute toxic encephalopathy and required dialysis. Interviews with facility leadership revealed that no incident report was filed, and no QAPI meeting was conducted to address the medication error, investigate the root cause, or implement corrective actions as required by the facility's own policies and procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in the facility's pressure ulcer prevention and care protocols, resulting in inadequate care for residents at risk or with existing pressure ulcers.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A facility failed to prevent the development of an avoidable, facility-acquired, unstageable pressure injury in a resident who was admitted with intact skin on the sacrococcyx area. The resident, who had a history of post laminectomy syndrome, spinal cord disease, kidney cancer, and bone tumor, was dependent on staff for toileting and bathing and required assistance for turning and repositioning. Despite physician orders and facility policy requiring repositioning every two hours, documentation showed multiple shifts where the resident was not turned or repositioned as required. The resident's care plan and physician orders specified the need for turning and repositioning every two hours, as well as regular checks for incontinence. However, facility records indicated that on at least fourteen occasions, staff failed to turn and reposition the resident during entire shifts. There was no documentation explaining these omissions, nor was there evidence that staff updated the care plan or documented any refusals of care by the resident, as required by facility policy. Interviews with staff revealed that some believed the resident refused to be woken for repositioning, but this was not communicated to nursing staff or documented in the medical record. As a result of these failures, the resident developed a stage 2 pressure injury on the sacrococcyx, which deteriorated to an unstageable wound and ultimately to a stage 4 pressure injury after debridement at an acute care hospital. The wound became infected, delaying further medical treatment for the resident's underlying conditions. Family members reported that staff did not consistently reposition the resident or provide necessary padding when the resident was in a wheelchair, and that the resident required assistance and reminders to change position due to loss of sensation in the lower body.
Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address offloading and pressure relief for a resident who was at risk for pressure injuries while sitting in a wheelchair. Upon admission, the resident had no pressure injuries to the sacrococcyx area and was admitted with multiple diagnoses, including post laminectomy syndrome, spinal cord disease, and cancer. The resident was dependent on staff for toileting and bathing and required assistance for mobility, with no feeling in the lower body due to spinal surgery. Over the course of the resident's stay, documentation showed the development and deterioration of a pressure injury on the sacrococcyx area, progressing from no injury to a stage two, and eventually to an unstageable pressure injury. Interviews with staff and family revealed that the resident frequently sat in a wheelchair for extended periods while visiting with family, sometimes without appropriate padding or repositioning. Staff confirmed that there were no specific care plan interventions or physician orders in place to address offloading or pressure relief while the resident was in the wheelchair, despite the resident's inability to reposition independently. The Director of Nursing acknowledged that the care plan did not include interventions for offloading pressure while the resident was in bed or in the wheelchair, and that care plans are essential for guiding care and preventing further skin breakdown. The facility's policy required care plans to be updated to reflect current interventions, but this was not done in the resident's case, contributing to the progression of the pressure injury.
Delay in Initiation of PT/OT Services Due to Authorization Lapse
Penalty
Summary
A deficiency occurred when a resident with impaired mobility and diagnoses of muscle wasting, atrophy, and muscle weakness was not provided with timely physical therapy (PT) and occupational therapy (OT) services as ordered by their physician. The resident required moderate assistance with activities of daily living, including toileting, bathing, dressing, and transfers, and used a manual wheelchair. The Minimum Data Set (MDS) confirmed the resident's intact cognition and functional limitations. The physician's order for PT and OT services was placed, but there was a 30-day delay before the therapies were initiated. The delay was attributed to the rehabilitation department not following up on the required authorization for therapy services. The Director of Rehabilitation (DOR) acknowledged responsibility for tracking and following up on therapy orders and authorizations but did not act until a month after the initial order. The Clinical Chief Officer (CCO) confirmed that the facility's process requires the rehabilitation department to ensure timely authorization and implementation of therapy orders, which typically should not exceed one week. Facility policy and procedure documents reviewed indicated that the DOR is responsible for tracking residents' therapy needs and ensuring timely and accurate clinical documentation. The policies also outlined the responsibilities of the supervising occupational therapist to confirm and implement therapy orders, consult with physicians, and coordinate care. Despite these policies, the resident's therapy services were delayed, resulting in a 30-day gap between the order and the initiation of PT and OT evaluations and treatments.
Failure to Doff PPE and Perform Hand Hygiene Exiting EBP Room
Penalty
Summary
Restorative Nurse Assistant 1 (RNA 1) failed to properly remove personal protective equipment (PPE) and perform hand hygiene when exiting the room of a resident who was on Enhanced Barrier Precautions (EBP). The resident in question had multiple diagnoses, including end-stage renal disease, dependence on dialysis, type 2 diabetes, and pressure ulcers, and was on EBP due to the presence of a dialysis port and a recent lower extremity amputation. Facility policy and posted signage required staff to don PPE before entering and doff PPE and perform hand hygiene before exiting the resident's room. On the day of the incident, RNA 1 was observed exiting the resident's room wearing gloves and a gown, walking into the hallway to retrieve an oxygen tank, and then re-entering the room without removing PPE or performing hand hygiene. This action was contrary to the facility's infection prevention and control policy, which was confirmed by interviews with the Registered Nurse Supervisor, Director of Quality Assurance, and Chief Clinical Officer. All confirmed that PPE should be removed and hand hygiene performed prior to leaving the resident's room to prevent the spread of infection. RNA 1 acknowledged during an interview that she failed to remove her PPE and perform hand hygiene before exiting the room, stating she was focused on retrieving the oxygen tank and did not realize her mistake until after the fact. The facility's policy, as reviewed, clearly outlined the steps for PPE use and removal in accordance with EBP and standard precautions, emphasizing the importance of these measures in preventing cross-contamination and the spread of multidrug-resistant organisms.
Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
Penalty
Summary
The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall. This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured. The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.
Removal Plan
- Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
- Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
- Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
- A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
- The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
- The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
- The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
- An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
- Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
- All residents were identified as potentially affected by the deficient practice.
- The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
- A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
- Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
- Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.
Failure to Secure Rehabilitation Equipment Leads to Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when a resident obtained a rehabilitation dowel without authorization and used it to physically assault two other residents. The dowel, a piece of equipment intended for therapy, was stored unsecured in the rehabilitation room, which was not consistently locked or supervised outside of therapy hours. Staff interviews and observations confirmed that dowels and other equipment were accessible on the wall, and the rehabilitation room door was only locked when staff left the facility for the day, not during all unsupervised periods. One resident, with a history of anxiety disorder and cognitive decline following a stroke but assessed as having intact cognition, accessed the unsecured dowel and used it to strike another resident on the left arm and, in a separate incident, to hit a different resident on the right arm, right shoulder, and face before pushing her to the floor. The assaulted resident, who had hemiplegia and hemiparesis following a stroke and used a walker for mobility, sustained a non-displaced fracture of the mid sacrum and required transfer to an acute care hospital for evaluation and pain management. Multiple staff and resident interviews corroborated the sequence of events, including the use of the dowel as a weapon and the lack of immediate staff intervention to prevent the assault. The facility did not follow its own policy and procedure regarding the prevention, reporting, and correction of abuse, neglect, and mistreatment. The investigation revealed that staff failed to secure the rehabilitation room and its equipment, did not prevent the resident from accessing the dowel, and did not implement interventions to address the resident's behavioral risks or prevent further incidents. The lack of supervision and security measures directly contributed to the occurrence of physical abuse and injury among residents.
Failure to Log and Investigate Grievance Regarding Resident Care
Penalty
Summary
The facility failed to properly log and investigate a grievance regarding the care of a resident, as per their established policy and procedures. The resident, who was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence, had severe cognitive impairment and was unable to communicate effectively. The resident's responsible party (RP) reported multiple complaints about the lack of Activities of Daily Living (ADL) care, such as bathing and toileting, which were not formally logged or investigated by the facility. The responsible party observed the resident in soiled briefs and ungroomed during visits and expressed concerns to a registered nurse (RN) on several occasions. Despite these complaints, the RN did not initiate the grievance process, mistakenly believing the issues were resolved after discussions with the responsible party. This oversight led to a lack of formal investigation and follow-up, potentially delaying necessary care and services for the resident. Interviews with facility staff, including the Social Services Director, Social Services Assistant, and the Administrator, revealed that the grievance process was not followed. The Social Services Assistant was not informed of the complaints, and the Administrator was unaware of the issues. The facility's policy requires grievances to be investigated and resolved promptly, but this was not adhered to, resulting in a violation of the resident's rights and a potential delay in care.
Failure to Include Responsible Party in Care Planning
Penalty
Summary
The facility failed to conduct timely Interdisciplinary Team (IDT) meetings for Resident 1, who was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence. The IDT meetings, which are crucial for planning and updating the resident's care, did not include Resident 1's Responsible Party (RP1) as per the facility's policy. Despite multiple hospitalizations and severe cognitive impairment of Resident 1, the last IDT meeting involving RP1 was held in September 2024, leaving RP1 without the opportunity to discuss specific concerns about Resident 1's care, including the management of multiple pressure ulcers. RP1 expressed dissatisfaction with the lack of involvement in the care planning process and reported that Resident 1's wounds seemed to worsen after each return from the hospital. The facility's Director of Quality Assurance confirmed that RP1 was not included in IDT meetings held in early 2025 and acknowledged the failure to ensure RP1's participation. The facility's policies require that the IDT, in conjunction with the resident and their family, develop and update a comprehensive care plan, especially after hospital readmissions. The lack of regular IDT meetings and RP1's exclusion from the process potentially delayed necessary care interventions for Resident 1.
Failure to Assess and Monitor Resident's Condition After Incident
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident, identified as Resident 1, after an incident involving a Restorative Nursing Assistant (RNA1). RNA1 accidentally dropped a water bottle on Resident 1's left foot, causing pain. Despite the incident, there was no documented Change of Condition (COC) assessment, and the physician and family were not notified. The RNA1 admitted to not reporting the incident to the charge nurse, which led to a lack of proper assessment and monitoring of the resident's condition. Resident 1, who had a history of chronic respiratory failure, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease, experienced worsening pain, swelling, and drainage from the left big toe. Despite these symptoms, there was no reassessment or monitoring of the wound condition after the initial COC was identified. The Treatment Administration Record indicated a treatment plan for the wound, but weekly assessments were not conducted as required by the facility's policy. Interviews with various staff members, including a Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Quality Assurance, revealed that the facility did not adhere to its policies for wound care and documentation. The lack of proper documentation and assessment of the resident's condition after the incident with the water bottle and the subsequent infection of the left big toe highlighted deficiencies in the facility's care and monitoring processes.
Failure to Prevent and Treat Pressure Injury
Penalty
Summary
The facility failed to provide adequate care for a resident who developed a Stage II pressure injury on the sacrococcyx, which progressed to a Stage IV pressure injury. The resident, who was in a persistent vegetative state and dependent on staff for activities of daily living, was admitted with multiple diagnoses, including chronic respiratory failure and a gastrostomy tube. Despite being at high risk for pressure injuries, the facility did not ensure consistent treatment and monitoring of the resident's pressure injury. The facility did not follow the physician's orders for treating the Stage II pressure injury, as the treatment was discontinued without documentation or explanation. The resident did not receive the prescribed wound care from November 8 to November 21, and there was a lack of weekly assessments and documentation of the pressure injury's progression. The interdisciplinary team recommended a consultation with a registered dietician, but this was not completed in a timely manner, delaying potential nutritional interventions that could have supported wound healing. The facility's policy required weekly wound assessments and documentation, but these were not consistently performed. The lack of regular assessments and failure to follow care plans contributed to the deterioration of the resident's pressure injury. The Director of Nursing acknowledged the systemic issue of inadequate documentation and monitoring, which led to the avoidable progression of the pressure injury to Stage IV.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident identified as high risk for falls and injuries. The deficiency involved a Certified Nurse Assistant (CNA 2) leaving the resident unsupervised in the bathroom, contrary to the facility's Fall Prevention and Management Program policy. This policy mandates that residents receive adequate supervision and assistive devices to prevent accidents. The resident, who had a history of falls and was diagnosed with osteoporosis and kyphosis, was left unattended, leading to a fall and subsequent injuries. The resident's care plan, which highlighted the risk for falls, required staff to anticipate and meet the resident's needs, including the use of a front wheel walker (FWW) as needed. Despite this, CNA 2 left the resident alone in the bathroom to assist another resident, resulting in the resident attempting to ambulate back to bed using the FWW. The resident lost balance while trying to kick the bathroom door shut, leading to a fall that caused multiple fractures. The resident was later transferred to a General Acute Care Hospital for evaluation and treatment. Interviews with facility staff, including CNA 2, a Licensed Vocational Nurse, a Registered Nurse, and the Director of Staff Development, confirmed that the resident was forgetful and required assistance with ambulation. They acknowledged that the fall was preventable if the resident had not been left unattended. The facility's policy emphasized the importance of providing an environment free from accident hazards and ensuring supervision to prevent avoidable accidents, which was not adhered to in this case.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation protocols, as observed during a survey. A bottle of Lysol bleach cleaner was improperly stored in the dry food storage area, posing a risk of chemical contamination. Additionally, the ice machine drain was found to have dirt and debris, which could lead to bacterial growth. The facility also failed to label prepared food items in the refrigerator with preparation and use-by dates, increasing the risk of serving expired food to residents. Furthermore, the freezer temperature logs were not consistently completed, which is crucial for ensuring food is stored at safe temperatures. Interviews with staff, including dietary aides and the dietary supervisor, confirmed these deficiencies. The staff acknowledged the potential risks associated with these practices, such as food spoilage and the possibility of residents consuming contaminated or expired food. The facility's policies and procedures, which require proper labeling, storage, and sanitation practices, were not followed, leading to these observed deficiencies.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 22 and Resident 100, by not ensuring timely response to call lights. Resident 22, who had intact cognition and required substantial assistance due to conditions such as hemiplegia, diabetes, and heart failure, was left in pain without timely assistance. Despite pressing the call light and screaming for help, the resident's call was ignored by LVN 11, who was nearby but did not respond. It took over 25 minutes for a Restorative Nursing Assistant to attend to the resident, who was then given pain medication for severe pain. Resident 100, who had hemiplegia, dementia, and a contracture of the right elbow, was found with the call light clipped to the curtain, out of reach. This resident, who lacked the capacity to make decisions, was at risk of falls and accidents due to the inability to call for help. LVN 13 and CNA 6 acknowledged the improper placement of the call light, which should have been within the resident's reach to ensure safety and timely assistance. The facility's policy required call lights to be answered promptly and within reach of residents, yet these standards were not met, leading to potential risks for the residents involved. The Director of Staff Development and Chief Clinical Officer confirmed the importance of timely response to call lights to prevent unrelieved pain and delays in care, as outlined in the facility's policies.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 34.48% error rate during medication administration for four residents. Resident 129 did not receive the full dose of Amlodipine as the medication was not properly mixed with water before administration via gastrostomy tube, leaving residual medication in the cup. This oversight was acknowledged by the LVN responsible, who admitted to not following the facility's policy of mixing crushed medication with water and ensuring the full dose was administered. Resident 80's blood pressure was not reassessed before administering medication, despite having specific parameters for holding or administering blood pressure medications. The LVN relied on pre-recorded vital signs taken by a CNA earlier in the morning, which were not verified before medication administration. This practice was against the facility's policy, which requires the charge nurse to check vital signs prior to administering medications with specific parameters. Residents 12 and 230 experienced delays in receiving their medications, with administration times exceeding the facility's policy of a 60-minute window around the scheduled time. Resident 12's seizure and anticoagulant medications were administered significantly late, and the physician was not notified before the late administration. Similarly, Resident 230's Metoclopramide doses were consistently administered late, with the LVN citing workload as the reason for the delay. These actions were contrary to the facility's guidelines for timely medication administration.
Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was free from significant medication errors. The resident, who had a history of hemiplegia, cerebral palsy, and convulsions, was not administered their prescribed medications, including Phenytoin, Phenobarbital, and Heparin, at the scheduled times. The medications were given several hours late on multiple occasions, which was not in accordance with the physician's orders. On specific dates, the resident's medications were administered significantly later than the scheduled times. For instance, on one occasion, the morning dose of Phenytoin was given over three hours late, and the subsequent dose was administered less than four hours after the late morning dose. Similarly, Heparin, which was supposed to be administered every 12 hours, was given late and not in accordance with the prescribed schedule. The Licensed Vocational Nurse (LVN) responsible for administering the medications acknowledged the delay and admitted to not informing the physician about the late administration before proceeding. The facility's policy required medications to be administered within a one-hour window of the scheduled time, and any deviations should have been communicated to the physician for further instructions. However, the physician was only notified after the medications were administered late. The Registered Nurse (RN) confirmed that the late administration could lead to potential overdosing, especially with medications like Phenytoin and Heparin, which require precise timing to avoid adverse effects. The failure to adhere to the medication schedule and notify the physician in a timely manner constituted a significant medication error.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices in several instances, leading to potential cross-contamination and risk of infection among residents. For Residents 126 and 500, the facility did not ensure that oxygen tubing and bags were changed and labeled weekly. This oversight was confirmed by LVN 8, who acknowledged that the tubing and bags were not dated, making it unclear when they were last changed. The facility's policy requires these items to be changed weekly to prevent bacterial growth that could lead to respiratory infections. Resident 218's tube feeding and water bags were not labeled or dated, as observed by LVN 8. The facility's policy mandates that these bags be changed every 24 hours to prevent spoilage and potential stomach issues. Additionally, a licensed nurse failed to remove her PPE before exiting Resident 517's room, which could lead to contamination in the hallway. This was acknowledged by RN 3, who admitted the mistake and the potential for spreading infection. In another instance, CNA 4 did not follow proper procedures after finding feces on the floor in Resident 106's room. Instead of calling housekeeping immediately, CNA 4 attempted to clean the area with dry towels and forgot to place a sign to prevent others from stepping on the contaminated floor. Furthermore, a visitor in Resident 169's room was not wearing the required PPE despite the resident being on contact isolation for Candida Auris. LVN 12 noted the oversight and the need to inform the visitor about the necessary precautions.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect during meal assistance. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident, identified as Resident 17, while assisting her with eating. This action was contrary to the facility's policy and procedure, which emphasized providing a dignified dining experience to promote residents' well-being and self-esteem. The resident, who had severe cognitive impairments and required substantial assistance with eating, was not provided with the appropriate level of care that aligned with her care plan, which specified one-on-one assistance during meals. Interviews with various staff members, including other CNAs and the Director of Staff Development, confirmed that the proper procedure for feeding residents involves sitting at eye level to ensure clear communication and comfort for the resident. The Chief Clinical Officer also noted that feeding residents at eye level could prevent aspiration by allowing the CNA to visually monitor the resident's mouth. The facility's policy on dignity, revised in October 2024, was not adhered to in this instance, as the CNA's actions did not align with the established guidelines for maintaining resident dignity during meals.
Failure to Reassess PASARR for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to reassess the Preadmission Screening and Resident Review (PASARR) for a resident diagnosed with mental illness and placed on antipsychotic medication. The resident, who was admitted with diagnoses including unspecified psychosis, end-stage renal disease, anxiety disorder, and unspecified dementia, was not reassessed for PASARR Level 1 after being placed on antipsychotic medication. This oversight was identified during a review of the resident's records, which showed that the initial PASARR Level 1 Screening did not indicate a serious diagnosed mental disorder, and therefore, a Level 2 Screening was not conducted. The Director of Medical Records acknowledged missing the resident's status change and the need for a new PASARR Level 1 Screening. The Minimum Data Set Coordinator also confirmed that the facility missed the PASARR Screening, which should have been updated once the resident was placed on antipsychotic medication. The facility's policy requires a new Level 1 screening if there is a significant change in the resident's condition, but this was not done, potentially delaying necessary care and services for the resident.
Deficiencies in Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure the safe administration of blood pressure medications for two residents, leading to deficiencies in care. For Resident 129, the Licensed Vocational Nurse (LVN) did not mix the crushed Amlodipine medication with water before administering it via the gastrostomy tube (GT), resulting in medication residue remaining in the cup. This practice risked the resident not receiving the full dose of the medication, which is crucial for managing hypertension. The facility's policy required that medications be mixed with water and the cup rinsed to ensure the full dose is administered, but this was not followed. For Resident 80, the facility failed to reassess abnormal blood pressure values before administering medications with specific parameters. The LVN relied on blood pressure readings taken by a Certified Nurse Assistant (CNA) earlier in the morning, which were not verified before medication administration. The LVN initially decided to hold certain medications based on these unverified readings but later administered Metoprolol after rechecking the blood pressure. The facility's policy required that vital signs be checked before administering medications, especially those with parameters, but this was not adhered to. The deficiencies in medication administration for both residents highlight a lack of adherence to established protocols and procedures. Resident 129's cognitive impairment and dependence on staff for all activities of daily living further emphasize the need for careful medication management. Similarly, Resident 80's complex medical conditions, including hypotension and atrial fibrillation, necessitate precise monitoring and administration of medications. The failure to follow proper procedures placed both residents at risk of not receiving appropriate care.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medication carts were properly secured, leading to potential unauthorized access to medications. During a medication pass observation, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended in the hallway while attending to a resident. This oversight was noticed by a Registered Nurse (RN), who subsequently locked the cart. The facility's policy requires medication carts to be locked or attended by authorized personnel, highlighting a lapse in adherence to this policy. In another instance, a medication cart contained home medications for a resident, including a controlled substance, without a physician's order. The medications were brought from the resident's home and were not intended for use by the facility. The LVN responsible for the cart was unaware of the presence of a controlled medication, Lorazepam, among the home medications. The facility's policy dictates that unauthorized medications should not be accepted and should be returned to the family or disposed of if unclaimed. Additionally, the facility failed to properly label an opened medication for a resident, which could lead to the use of expired medication. An LVN found an opened foil pack of Ipratropium-Albuterol Inhalation Solution without an open date, contrary to manufacturer guidelines that require the medication to be used within two weeks of opening. This oversight could compromise the medication's potency, potentially affecting the resident's treatment for breathing issues.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food requests and preferences of a resident, identified as Resident 76, which had the potential to impact her nutritional needs. Resident 76, who has diabetes mellitus and pulmonary hypertension, was on a controlled carbohydrate diet and had specific food preferences documented, such as brown rice and wheat bread. Despite these documented preferences, the resident reported that the kitchen frequently ran out of requested items like gravy, chicken noodle soup, bacon, and cream of wheat, leading to her receiving alternative foods that did not align with her preferences. This issue was corroborated by interviews with staff, including a Certified Nursing Assistant and a Dietary Aide, who confirmed that popular food items often ran out, affecting residents' satisfaction and potentially their appetite. The Dietary Supervisor admitted to not regularly checking in with residents unless there was a complaint, indicating a lack of proactive engagement with residents' dietary needs. The facility's policy on food preferences, which requires staff to assess and document individual preferences, was not effectively implemented, as evidenced by the miscommunication between nursing and kitchen staff. The Assistant Cook acknowledged that additional food could be prepared to meet residents' requests, but this was not consistently done, leading to dissatisfaction among residents like Resident 76, who expressed a preference for specific items such as raisin toast and bacon.
Deficiency in QAPI Committee's System for Resident Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to establish a system for medication management and safety, falls and fall-related injuries, and pressure ulcers monitoring. This deficiency resulted in residents not receiving necessary care, leading to medication errors, injuries related to falls, and inadequate monitoring and documentation of pressure injuries. During an interview, the Administrator acknowledged the ongoing work but could not provide evidence of measures to prevent medication errors, falls, and pressure injuries. The facility's policy and procedure, revised in January 2025, indicated a need for a systematic and proactive process to improve resident care, outcomes, and safety, which was not effectively implemented.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy when administering antibiotics to a resident without meeting the established criteria for appropriate use. Specifically, Resident 98 was prescribed Ampicillin Sodium Injection Solution for a urinary tract infection, despite not meeting Loeb's or McGeer's criteria for antibiotic use. This oversight was identified during a review of the resident's records, which showed no documentation indicating that the physician was notified about the lack of criteria fulfillment. Resident 98, who was admitted with conditions including hemiplegia, hemiparesis, and neuromuscular dysfunction of the bladder, was receiving antibiotics without proper justification. The Director of Quality Assurance confirmed that the resident's symptoms did not meet the necessary criteria and acknowledged the absence of physician notification. The Chief Clinical Officer also noted the potential negative outcomes of administering antibiotics without meeting the criteria, such as the risk of multidrug-resistant organisms.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to offer, educate, and track influenza vaccinations for residents as per its policy, specifically for one of the five sampled residents. Resident 218, who was admitted with a diagnosis of hemiplegia and hemiparesis following a cerebrovascular infarction, was found to have moderately impaired cognition and was dependent on assistance for hygiene, bathing, and dressing. Despite being eligible for the 2024-2025 influenza vaccine, there was no documentation indicating that the vaccine was offered, education was provided, or that the resident declined the vaccine. During interviews, the Director of Quality Assurance confirmed the lack of documentation and emphasized the importance of offering vaccinations to prevent the spread of infection. The Chief Clinical Officer also highlighted the significance of offering the influenza vaccine to protect residents and prevent potential outbreaks. The facility's policy, revised in October 2019, mandates offering the vaccine to all eligible residents and employees, providing education on its benefits and side effects, and documenting the vaccination or refusal in the medical record. However, these procedures were not followed for Resident 218, leading to the deficiency.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, educate, and document coronavirus vaccinations for two residents, which was not in compliance with the facility's policy. Resident 218, who was admitted with hemiplegia and hemiparesis following a cerebrovascular infarction, had moderately impaired cognition and was dependent on assistance for hygiene, bathing, and dressing. Despite being eligible for the 2024-2025 coronavirus vaccine, there was no documentation indicating that the vaccine was offered, education was provided, or that the resident declined the vaccine. Similarly, Resident 121, who was admitted with chronic respiratory failure and dependence on a respirator, had severely impaired cognition and was also dependent on assistance for hygiene, bathing, and dressing. The facility's records did not show that the 2024-2025 coronavirus vaccine was offered, education was provided, or that the resident declined the vaccine. The Director of Quality Assurance confirmed the lack of documentation and emphasized the importance of offering vaccinations to prevent the spread of infection. The facility's policy required that all residents be offered vaccines unless medically contraindicated, and that education and any refusals be documented in the resident's medical record.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, violating the resident's right to dignity and respect. During an observation, it was noted that a Certified Nursing Assistant (CNA7) left the privacy curtain open while Resident 23 was half-naked after a shower. The CNA left the room to get towels, leaving the resident exposed to the view of roommates and others. This incident occurred despite the facility's policy requiring staff to maintain and protect resident privacy during personal care. Resident 23, who was admitted with diagnoses of anxiety, major depressive disorder, and schizoaffective disorder, was dependent on staff for all activities of daily living. During an interview, CNA7 acknowledged the mistake, stating that the privacy curtain should have been closed, and assistance should have been called for. The Chief Clinical Officer also confirmed the need for staff to ensure privacy curtains are fully closed to prevent residents from feeling embarrassed or ashamed.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to comply with the requirement of providing at least 80 square feet per resident in multiple resident bedrooms, as observed during the annual recertification survey. The Client Accommodations Analysis Form (CAAF) completed by the facility on February 15, 2025, revealed that 83 rooms did not meet the required space per resident. These rooms were identified as having less than 80 square feet per resident, which could potentially impact the quality of care, privacy, and quality of life for the residents. Despite this, during the survey, no immediate concerns or problems with privacy, safety, and residents' care were observed, and the Administrator reported no complaints from residents regarding room crowding or mobility issues. The facility plans to request a room waiver.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for a resident with a history of craniectomy and pressure ulcers. The resident's responsible party was not provided with updates regarding the resident's wound care treatments, as agreed upon during an interdisciplinary team meeting. Despite the agreement to provide weekly updates after the physician wound consultant's visits, there was no documentation indicating that the responsible party was notified of the wound care consultant's findings or any changes in the resident's wound care treatments. The resident's care plan required the resident to wear a helmet when out of bed, during transfers, and when sitting upright due to the craniectomy. However, during a transfer to a general acute care hospital, the facility failed to ensure the resident was wearing a helmet, putting the resident at risk for a head injury. The Director of Nursing acknowledged that the resident was not wearing a helmet during the transport, which was a violation of the care plan. The facility's policies and procedures required wounds to be measured and reviewed weekly, with updates provided to the primary care provider and family. However, the facility did not adhere to these policies, as evidenced by the lack of communication with the resident's responsible party regarding wound care updates. This failure to communicate and adhere to the care plan resulted in the resident and their responsible party being unable to actively participate in the resident's plan of care.
Inaccurate Pressure Ulcer Staging in Resident Care
Penalty
Summary
The facility failed to ensure accurate classification of a pressure ulcer for a resident, leading to a deficiency in wound care management. The resident, who was at risk for developing pressure ulcers and had cognitive impairments, was initially assessed with a Stage 4 pressure ulcer on the left gluteus. However, a subsequent assessment incorrectly classified the wound as Stage 3, which is not permissible according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. This misclassification was identified during an interview with the Quality Assurance Nurse, who confirmed that wounds cannot be reverse staged, meaning a wound initially classified as Stage 4 cannot be downgraded to Stage 3. The Director of Nursing also acknowledged that reverse staging is not allowed and emphasized that inaccurate wound assessments can lead to miscommunication and delays in care. The facility's policy, aligned with NPUAP guidelines, requires consistent and accurate wound staging to ensure appropriate clinical information is available for treatment decisions. The deficiency was identified through interviews and record reviews, highlighting the potential for delayed care and services due to the incorrect classification of the resident's pressure ulcer.
Failure to Monitor Resident at Risk for Wandering Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident assessed at risk for wandering, resulting in the resident eloping from the facility. The resident, who had a history of mild cognitive impairment and diabetes mellitus, was not provided with a care plan addressing his risk for wandering. Despite being identified as at risk for wandering, there was no system in place to monitor the resident's whereabouts effectively, leading to his absence going unnoticed for over two hours. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's wandering risk. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) were not informed of the resident's risk status, and there was no clear guidance on the frequency of monitoring required for residents at risk of wandering. The facility's policy required a care plan to be implemented for residents at risk of wandering, but this was not done for the resident in question. The resident was last seen in the facility's front lobby and was able to leave the premises without being noticed. The absence of a care plan and inadequate communication among staff contributed to the failure to monitor the resident effectively, ultimately leading to the resident's elopement and subsequent risk of harm.
Removal Plan
- Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies.
- A door monitor was assigned for the back door entrance. The local Sheriff's office was also informed and assisted in looking for Resident 1. The local Sheriff's Office made multiple postings to social media and to other missing person's outreach. The Department of Motor Vehicle (DMV) was called to request if the facility could avail itself of any vehicle registered under Resident 1 to locate the resident and inform the sheriff's department.
- All exit doors are equipped with an alarm 24 hours and 7 days a week. Door monitors have been assigned to monitor two exit doors with the front door being monitored from 8 a.m. to 8 p.m. and the back door and back patio from 6:30 a.m. to 8 p.m. The alarms are activated after the door monitors leave for the day.
- The Interdisciplinary Team convened to revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing.
- A root cause analysis revealed key issues in the wandering and elopement process, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The ED will oversee corrective actions initiated and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey.
- Any new issues found during medical record audits and wandering, and elopement system audit will be presented to the Wandering/Elopement IDT members for immediate action.
- Specific staff involved in implementing the corrective actions: Medical Director, ED, CCO, Director of Staff Education, and RCN.
- Identification of other residents who may need to be included: All residents who were identified as high risk for wandering/eloping were identified at risk for the identified deficient practice.
- The IDT convened to revise the wandering and elopement policy.
- The residents with identified risk will be added to the specific instructions on the Electronic Medical Record (EMR) banner for each resident.
- The EMR's wandering, and elopement risk assessment was updated as well as the care plan library to include risk score intervention for frequency of routine checks for location.
- The elopement/wandering binder that already contained the list of all the residents with moderate/ serious significant risk for wandering and elopement was reviewed.
- Wandering and elopement risk assessment and missing resident policy has been updated.
- The Medical Records Department will use a monitoring tool to audit the documented frequency of routine checks/location for residents identified with a risk for wandering or elopement, based on their established care plans.
- The Wandering/Elopement IDT will review post elopement events within 24-72 hours of incident for any revision of assessment need and/or plan of care interventions.
- Training and Education Started by Director of Staff Education and/or Designee.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified as wandering/elopement risk.
- Inservice training for staff nurses was started on how to assess residents with elopement/wandering risk.
- Inservice training for staff nurses was started on how to determine frequent monitoring needs based on elopement/wandering episodes and how to document the monitoring in the electronic medical records.
- Inservice training on staff nurses was started on how to recognize behaviors that place residents at risk for elopement and who to report and how to follow up with residents.
- Inservice training for staff nurses was started on how to identify residents that are at high risk for wandering using an orange band.
- Inservice training for staff nurses was started on elopement drill and what to do for missing residents.
- The assigned door monitors were provided in-service training on how to monitor residents based on elopement binder list.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident with a history of banging her arms against the side rails of her bed. This deficiency was identified during a review of the resident's records and interviews with staff and the resident's responsible party. The resident, who has severe cognitive impairment and requires substantial assistance for bed mobility, was observed with a bruise on her right forearm, which was attributed to her behavior of holding onto and jerking against the side rails. The resident's responsible party expressed concern that the facility had not updated her on interventions to prevent further injuries, and the facility had previously used padding on the side rails but had since removed it. Interviews with staff, including a CNA and the Director of Quality Assurance, confirmed that no interventions were currently in place to prevent the resident from injuring herself on the side rails. The care plan section of the resident's clinical record lacked any interventions addressing the resident's behavior of banging her hands against the side rails. The Director of Nursing acknowledged the importance of developing and implementing resident-centered care plans to ensure appropriate care. The facility's policies and procedures emphasized the need for care plans to be used in developing daily routines and for changes in the resident's condition to be reported for assessment and care plan review. However, the facility failed to adhere to these policies, resulting in the resident being at risk for further injury and skin breakdown.
Infection Control Breach in Contact Isolation Protocols
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by nursing staff while caring for a resident on contact isolation due to a Clostridium difficile colitis infection. Observations revealed that a Licensed Vocational Nurse (LVN) entered the resident's room without donning the required personal protective equipment (PPE) such as gloves and a gown, and used hand sanitizer instead of washing hands with soap and water after contact with the resident. This was contrary to the facility's policy, which mandates the use of soap and water for hand hygiene in cases of C. diff infections. Additionally, a Certified Nursing Assistant (CNA) was observed providing care to the same resident and subsequently assisting the resident's roommate, who was also on contact isolation, without wearing a gown. The CNA's pants came into contact with the roommate's blanket, and the CNA used hand sanitizer instead of washing hands with soap and water. Interviews with staff confirmed the importance of following proper PPE protocols and handwashing procedures to prevent cross-contamination, as outlined in the facility's policies.
Failure to Notify Physician and Administer Insulin
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not notifying the physician in a timely manner when the resident experienced episodes of loose watery stool. The resident, who was admitted with diagnoses including diabetes mellitus and other conditions, had multiple episodes of watery stool over several days. Despite these occurrences, there was a delay in notifying the physician and conducting a Change in Condition Evaluation (COC), which was only done after several episodes had already occurred. This delay in communication and assessment potentially contributed to the resident's worsening condition. Additionally, the facility did not administer insulin as ordered by the physician. On a specific date, the resident did not receive the scheduled dose of Humalog insulin at lunchtime, and there was no documentation of the resident's blood sugar level at that time. This lack of administration and documentation was confirmed during interviews with nursing staff, who acknowledged the missing records and the uncertainty of whether the insulin was given. The absence of proper documentation and administration of insulin could have contributed to the resident's uncontrolled blood sugar levels. Furthermore, the facility failed to notify the physician when the resident's blood sugar remained high despite the administration of insulin. The resident's blood sugar levels were consistently elevated, and there was a lack of timely communication with the physician regarding these high levels. The resident's condition deteriorated, leading to a transfer to a general acute care hospital for further management. The facility's policy and procedure for observing, recording, and reporting changes in condition were not adequately followed, resulting in a deficiency in the quality of care provided to the resident.
Infection Control Deficiencies in N95 Fit Testing and Linen Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control measures by not conducting fit testing for N95 masks on six out of ten staff members. The Infection Preventionist Nurse (IPN) confirmed that these staff members were not up to date with their N95 mask fit tests, which are required upon hire and annually. The IPN and RN Supervisor both emphasized the importance of fit testing to ensure that staff members have the correct size mask for protection against COVID-19 and other respiratory illnesses. The lack of fit testing could result in staff wearing improperly sized masks, potentially compromising their protection. Additionally, the facility did not handle soiled linens in a safe and sanitary manner. A Certified Nursing Assistant (CNA) was observed swinging a plastic bag containing dirty bibs back and forth towards her body before disposing of it in a barrel outside the facility. The CNA acknowledged that this action could lead to the bag breaking and contaminating the surrounding area, posing a risk of infection spread. The IPN confirmed that staff should not agitate or swing bags of soiled linens to prevent contamination, as outlined in the facility's policy and procedure for handling soiled laundry.
Failure to Monitor Antibiotic Use Leads to C. difficile Infection
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one of the residents by not monitoring and addressing the use of antibiotics. The resident was admitted with several diagnoses, including hemiplegia, diabetes mellitus, congestive heart failure, and bacteremia. Despite the resident's complex medical history, the facility did not monitor the use of Amoxicillin, an antibiotic prescribed for bacteremia, as indicated in the resident's Medication Administration Record. The resident received Amoxicillin for several days without proper surveillance, and there was no documentation of infection surveillance for the antibiotic usage. The lack of monitoring led to the resident developing a Clostridium difficile infection, confirmed by a stool exam. Interviews with facility staff, including a CNA and RN Supervisor, revealed that the resident exhibited symptoms such as watery stools and sleepiness. The Infection Preventionist Nurse confirmed that there were no documents or surveillance data indicating the monitoring of the resident's antibiotic use. The facility's policy on antibiotic stewardship emphasized the importance of monitoring antibiotic use to prevent adverse effects and infections like C. difficile, but this was not adhered to in this case.
Inadequate Hand Hygiene Practices by CNAs
Penalty
Summary
The facility failed to implement and maintain proper infection control procedures, as evidenced by the actions of two Certified Nurse Assistants (CNAs). During an observation, CNA 3 was seen not performing hand hygiene between resident care or when entering and exiting a resident room. In an interview, CNA 3 admitted to rushing and acknowledged the importance of hand hygiene in preventing the spread of infection. Similarly, CNA 1 was observed entering and exiting a resident's room without performing hand hygiene. CNA 1 admitted to being careless and recognized the risk of spreading infection to other residents and staff. The Infection Prevention Nurse (IPN) emphasized the importance of hand hygiene in preventing infection outbreaks. A review of the facility's Hand Hygiene Program policy, dated October 24, 2022, indicated that healthcare personnel should use an alcohol-based hand rub or wash with soap and water before and after touching a patient or the patient's immediate environment. Additionally, the facility's infection control policy, revised in October 2018, outlined objectives to prevent, detect, investigate, and control infections, maintaining a safe environment for personnel, residents, visitors, and the public.
Failure to Monitor and Notify Physician After PICC Line Removal
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident who had a Peripherally Inserted Central Catheter (PICC) line. The resident, admitted with osteomyelitis of the vertebra, had a physician's order to monitor the IV site for signs of complications every shift and to notify the physician of any abnormal changes. However, the PICC line was found on the floor, and the resident was unaware of how it was removed. The nurse documented the removal in the Electronic Medication Administration Record (EMAR) but did not notify the physician or continue monitoring the site for complications as required by the care plan and facility policy. The Unit Manager confirmed there were no orders to discontinue the PICC line and no documentation of physician notification or site monitoring after removal. Interviews with the Registered Nurse Supervisor and Senior Head Nurse revealed that the PICC line should have been measured to ensure it was removed intact, and the site should have been monitored for bleeding and swelling. The facility's policy indicated that any signs of complications should be reported to the physician, supervisor, and oncoming shift. The failure to follow these procedures placed the resident at risk for bleeding and infection after the removal of the PICC line.
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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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