Sunset Manor Conv Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 2720 Nevada Avenue, El Monte, California 91733
- CMS Provider Number
- 055104
- Inspections on file
- 36
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sunset Manor Conv Hosp during CMS and state inspections, most recent first.
A resident with COPD, anxiety, depression, intact cognition, and independence with ADLs had care plans identifying fall risk and hoarding behavior, with interventions to maintain a clutter-free environment and for the IDT to follow up on hoarding to protect others’ safety. Social services documented educating the resident about clutter-related safety hazards and the resident’s refusal to store belongings elsewhere, but no further follow-up or alternative interventions were recorded. On observation, the resident’s bed area was surrounded by boxes, crates, and bags of clothes, leaving little space to access the roommate’s bed, and both the roommate and a CNA reported staff had difficulty providing care due to the clutter. The facility therefore failed to implement the care-planned interventions to keep the area free of clutter.
Nursing staff did not implement a person-centered care plan for a resident with cognitive impairment and complex medical needs, failing to monitor symptoms of confusion and physical abusiveness as required by the care plan. Interviews and record reviews confirmed the absence of documentation or monitoring over several months, despite facility policy mandating such interventions.
A resident with multiple complex medical conditions and cognitive impairment received hydrocodone-acetaminophen via G-tube for pain, but the PRN order did not specify the required pain severity for administration. Nursing staff administered the medication for pain levels between 4 and 9, despite facility policy requiring clarification of such orders to indicate the appropriate pain level. Staff and the DON confirmed the order was incomplete and not entered according to policy.
Three residents were not properly informed about their right to formulate an advance directive (AD), with one resident not receiving any AD information and two others having inaccurately completed AD Acknowledgement Forms. Staff interviews confirmed the importance of AD documentation, and facility policy required providing this information and ensuring accurate records, but these procedures were not followed.
The facility did not act on pharmacist recommendations for two residents, including ordering a lab test to monitor for rhabdomyolysis risk in a resident receiving both a statin and fibric acid, and discontinuing Benadryl for another resident as advised. Both recommendations were documented but not implemented, leaving unnecessary medications in use.
Surveyors observed a bottle of basil pesto sauce in the kitchen freezer with an unreadable best by or use by date. The Assistant confirmed the date was not legible and recognized the importance of date marking for food safety. Facility policy requires all ready-to-eat foods to be clearly marked with a date to ensure proper consumption or disposal.
A resident who required substantial assistance for daily activities was found unable to reach their call light, which was wrapped outside the bedrail. The resident reported being unable to locate or access the device, and an LVN confirmed it was not within easy reach, contrary to facility policy requiring call lights to be accessible to residents.
A resident with diabetes, dysphagia, and a pressure ulcer, who was dependent on staff and preferred Vietnamese, was not provided with a communication board as required by the care plan. Staff relied on a coworker for translation, but no alternative communication method was available when that coworker was absent, contrary to facility policy.
A resident with diabetes, dysphagia, and a heel pressure injury was observed multiple times with both heels resting on the mattress, despite a physician's order to free float the heels using pillows. The resident was fully dependent on staff, and both staff and policy confirmed the need for heel offloading to prevent further pressure injury, but the intervention was not implemented.
A resident receiving hemodialysis with a physician-ordered daily fluid restriction did not have their intake monitored or limited as required. Nursing and dietary staff failed to document or enforce the fluid restriction, and the resident reported being unaware of any limits, consuming fluids freely. The DON confirmed there was no system in place to track or restrict the resident's fluid intake, contrary to facility policy and physician orders.
A resident who spoke only Spanish was asked to sign a binding arbitration agreement presented solely in English, without explanation in their preferred language. Staff interviews confirmed the resident did not understand the document, and facility policy required such agreements to be explained in a language the resident understands.
A room in the Sub Acute Unit was found to have five beds, with four occupied, exceeding the regulatory limit of four residents per room. Staff and the administrator confirmed the arrangement, and a waiver request was in process, but the room was not in compliance at the time of the survey.
The facility did not ensure that nine resident rooms met the required minimum of 80 sq ft per resident in multiple occupancy rooms. Staff and residents reported that there was enough space for care and mobility, and observations confirmed that care was provided without difficulty. The facility submitted a waiver request, stating that resident safety and care were not compromised by the current room sizes.
A facility failed to follow its infection control policies when an LVN did not wash hands with soap and water after caring for a resident with C. difficile, using hand sanitizer instead. The LVN cited the resident's roommate's use of the restroom as the reason. Interviews with the DON and IP confirmed the importance of proper handwashing to prevent infection spread.
A resident with severe cognitive impairment and multiple health conditions sustained a hand laceration due to a damaged bed remote control coil line. The facility failed to maintain the equipment in good condition, and the CNA did not prevent the resident from grabbing the hazardous coil, resulting in the injury requiring hospital treatment.
A resident with severe cognitive impairment sustained a laceration on the hand due to a damaged bed remote control coil line in an LTC facility. The outer plastic layer of the coil line was broken, exposing a sharp edge that caused the injury. The Maintenance Assistant revealed that checking the bed remote control was not part of routine tasks, leading to the oversight. The Director of Nursing emphasized the need for regular equipment checks to ensure safety.
The facility failed to maintain its infection control program for two residents with scabies. A resident was confirmed to have scabies, but a line list was not initiated immediately, and infection control measures were not implemented for another resident highly suspicious of scabies. The facility did not follow its infection control policy or local guidelines, compromising infection prevention efforts.
A resident's medication was left unattended at the bedside, contrary to professional standards. The resident, with type 2 diabetes and COPD, had Gabapentin capsules left in a medicine cup, which the resident saved for later use. The DON confirmed that medications should not be left at the bedside and must be observed being taken by residents, as per facility policy.
A CNA entered a COVID-19 isolation room without full PPE, wearing only an N95 mask, despite facility policy and posted precautions requiring a gown, gloves, face mask, and eye protection. The incident involved a resident exposed to a COVID-19 positive roommate. Interviews confirmed the PPE requirements, and the CNA acknowledged the need for full PPE to prevent virus spread.
A resident with contractures and functional quadriplegia did not receive proper nail care, as CNAs failed to trim and clean fingernails or notify LVNs about overgrown toenails. LVNs did not inform the SSD to arrange for a podiatrist. Observations confirmed the resident's nails were long and dirty, posing a risk of injury and infection. The facility's policy for regular nail care was not followed.
The facility failed to provide reasonable accommodation of needs for two residents. One resident with severe mobility limitations was unable to use the call light, and another high-risk fall resident had an inaccessible call light. Staff did not follow the facility's policies on call light accessibility and accommodation of needs.
The facility failed to provide Advance Directive (AD) information for two residents, leading to potential treatment against their will. One resident with type 2 diabetes and fluctuating decision-making capacity did not have a completed AD form, while another resident with hypertension and impaired cognition had no AD assessment performed. Interviews confirmed the facility did not follow its policy on documenting AD information upon admission.
The facility failed to provide appropriate care for two residents with catheters, leading to potential risks of trauma and infection. One resident's indwelling catheter was not connected to a stabilization device, and another resident's suprapubic catheter was not covered or secured, as observed by staff.
The facility failed to follow its P&P for enteral feeding for two residents. One resident's G-tube dressing was not changed as required, and another resident was lying flat during feeding, contrary to care plan instructions. These lapses had the potential to cause infection and aspiration.
The facility failed to ensure proper respiratory care and safety for two residents receiving oxygen therapy. One resident's nasal cannula tubing was not stored in a plastic bag when not in use, and another resident did not have a spare tracheostomy tube readily available at the bedside, contrary to facility policies.
The facility failed to attempt appropriate alternatives before installing bed rails for two residents with dementia and epilepsy. The assessments did not document how the attempted alternatives failed or consider other available options like bolsters or bumpers, contrary to the facility's policy.
The facility failed to provide a safe and sanitary environment, leading to potential infection risks for five residents. Issues included improper wound care for a resident, failure to change curtains during deep cleaning for two residents, and inadequate hand hygiene and PPE use by staff. These deficiencies were confirmed by facility staff and were against the facility's policies.
A facility failed to create a comprehensive care plan for a resident with multiple pressure injuries, despite the resident's high risk for developing such injuries. The absence of a detailed care plan for each injury was confirmed by nursing staff and the ADON, putting the resident at risk of worsening conditions due to lack of proper treatment and monitoring.
A facility failed to ensure a resident with a tracheostomy and chronic respiratory failure was provided with a Passy-Muir Valve (PMV) for effective communication. Despite a physician's order and staff training, the PMV was not utilized, leading to communication difficulties for the resident.
The facility failed to follow its own policy for pressure injury prevention for a resident with multiple pressure injuries. Despite an active MD order for bilateral heel protectors, the protectors were not observed on the resident, potentially worsening existing injuries. Staff interviews confirmed the oversight, highlighting a lapse in adherence to wound management protocols.
The facility failed to adhere to the prescribed turning and repositioning schedule for a resident with severe cognitive impairment and multiple stage 4 pressure ulcers. Observations and staff interviews revealed that the resident was left in the same position for extended periods, contrary to the facility's policy, leading to the potential for further skin damage and delayed wound healing.
The facility failed to ensure that a resident's right-hand splint was maintained and properly applied according to the care plan and facility policy. The resident, diagnosed with muscle wasting and contracture, was on a Restorative Nursing Program requiring splints for four hours daily. Observations and staff interviews confirmed non-compliance, placing the resident at risk for contractures and decline in physical function.
The facility failed to follow policy and procedure for the use of a Hoyer Lift, leaving a resident suspended in the air unsupervised. The resident, who had multiple medical conditions, was at risk of falling and sustaining serious injury due to the CNA operating the lift alone.
The facility failed to provide adequate supervision or assistance during meals for a resident with severe cognitive impairment and Parkinson's disease, leading to potential further weight loss. Observations revealed the resident struggled to eat independently due to tremors and was often left unattended, resulting in most of her food being untouched. Staff interviews indicated a lack of familiarity with the resident's needs and inconsistent documentation. The resident's weight log showed a significant decline, and the facility's policies on weight management and meal supervision were not followed.
The facility failed to label and date the midline intravenous catheter for a resident with type 2 diabetes mellitus and hyperglycemia, as required by the care plan and facility policy. This oversight was confirmed by the Infection Preventionist Nurse and the Assistant Director of Nursing, posing a potential risk of infection.
The facility failed to ensure accurate MDS assessments for two residents' discharge destinations. One resident discharged to a SNF was incorrectly coded as discharged to home, while another resident discharged to home was coded as discharged to a GACH. These errors were confirmed through record reviews and staff interviews, highlighting the importance of accurate coding for CMS reporting and resident care.
The facility failed to ensure that a resident room accommodated no more than four residents, as required by regulations. Room [ROOM NUMBER] had five beds, with four occupied, leading to potential privacy concerns and crowded conditions. The facility had requested a room waiver, stating that the room's size was adequate for the residents' needs and did not compromise their health and safety.
The facility failed to ensure that 14 rooms met the required 80 square feet per resident in multiple resident rooms. Despite the Administrator's plan to request a room waiver and staff and residents indicating that care was not compromised, the deficiency was noted due to non-compliance with regulatory square footage requirements.
Failure to Implement Care Plan to Control Clutter and Maintain Safe Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement the care plan interventions to maintain a safe, clutter-free environment for a resident at risk for falls. The resident was admitted with COPD, anxiety disorder, and depression, and had minor memory impairments but intact cognitive skills and independence with ADLs and mobility. The resident’s care plan documented a risk for falls related to incontinence and a history of falls, with interventions that included providing a safe environment free from spills and clutter. A separate care plan for hoarding behavior related to anxiety and depression directed the IDT to follow up with the resident regarding hoarding and to intervene as necessary to protect the rights and safety of others. Despite these identified needs and interventions, there were no updates or changes to the care plan after its initiation. Social services documented that the resident had been educated about how excessive clutter around the bed posed a safety hazard to both the resident and roommates, and that the resident refused offers to store belongings in an alternate location. However, from that point through the survey period, there were no additional notes in the medical record indicating ongoing assistance or encouragement to remove clutter from the room. During observation, the resident’s bed was surrounded by stacked boxes, crates, and bags filled with clothes, leaving minimal space to access the roommate’s bed. The roommate and a CNA reported that staff had difficulty assisting other residents in the room due to the clutter around the resident’s bed. This demonstrated that the facility did not carry out the care-planned interventions to maintain a safe, clutter-free environment as required by its comprehensive care plan policy.
Failure to Implement Person-Centered Care Plan and Monitor Resident Symptoms
Penalty
Summary
The facility failed to ensure that nursing staff implemented a person-centered care plan for a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a nontraumatic intracerebral hemorrhage, acute kidney failure, and neuromuscular dysfunction of the bladder. The resident was documented as having fluctuating capacity to understand and make decisions, and was assessed as moderately impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically identified increased confusion and physical abusiveness towards staff, with an intervention to monitor for worsening symptoms. Despite these documented needs and interventions, interviews and record reviews with nursing staff and the DON revealed that there was no documentation or evidence that the care plan was implemented, specifically regarding the monitoring of the resident's symptoms of confusion and physical abusiveness. The facility's own policy required that qualified staff be notified of their responsibilities and that interventions be carried out as specified in the care plan. However, for several months, there was no monitoring record or documentation to indicate that staff had followed the care plan interventions for this resident.
Failure to Specify Pain Severity in PRN Analgesic Order
Penalty
Summary
The facility failed to ensure that a licensed nurse implemented the facility's policy and procedure regarding medication orders by not specifying the severity of pain for a PRN hydrocodone-acetaminophen order for one resident. The resident, who had significant medical conditions including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and aphasia, was cognitively impaired and dependent on staff for care. The medication order for hydrocodone-acetaminophen via G-tube was written as 'every four hours as needed for pain' without indicating the pain severity (such as moderate or severe pain) or using a numerical pain scale, as required by facility policy. Record reviews and staff interviews confirmed that the medication was administered for pain levels ranging from 4 to 9, but the original order did not specify the pain level threshold for administration. Both nursing staff and the Director of Nursing acknowledged that the order should have been clarified with the physician to specify the appropriate pain level for administration. Facility policies required PRN orders to specify the condition for use and for staff to clarify incomplete orders, but this was not followed in this instance.
Failure to Provide and Accurately Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that three residents and/or their representatives were provided with information regarding their right to formulate an advance directive (AD). One resident, who was readmitted with diagnoses including diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis, was found to be cognitively intact and capable of making decisions. However, both the paper and electronic charts lacked documentation of an AD, and the resident confirmed not being informed about ADs or provided with related information by staff. For two other residents, review of their records revealed that the AD Acknowledgement Forms were filled out inaccurately. One resident, with moderate cognitive impairment and requiring significant assistance with daily activities, had an AD form that did not accurately indicate whether the resident or their responsible party had executed an AD. The Social Service Director acknowledged the form was not completed correctly. The other resident, who had intact cognition and required assistance with personal care, also had an AD form that was filled out incorrectly, as confirmed by the LVN who completed the form. Interviews with facility staff, including the DON and LVNs, confirmed the importance of AD documentation for understanding and recording residents' wishes regarding medical treatment. The facility's policy required providing information about ADs and ensuring proper documentation upon admission, but this was not followed for the three residents in question.
Failure to Act on Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly drug regimen review were acted upon for two residents. For one resident with diagnoses including diabetes, cirrhosis, and renal dialysis dependence, the pharmacist recommended ordering a fasting lipid panel (FLP) to monitor for increased risk of rhabdomyolysis due to concurrent use of Fenofibrate and Atorvastatin. The pharmacist also advised re-evaluating the necessity of continuing both medications together. This recommendation was documented, but there was no evidence that the physician responded or that the recommended laboratory test was ordered, and the resident continued to receive both medications. For another resident with a history of infectious and parasitic diseases, the pharmacist recommended discontinuing as-needed Benadryl and starting Claritin for chronic itching. Despite this recommendation being documented in the resident's record, there was no evidence that Benadryl was discontinued, and the medication remained active in the resident's orders. Nursing staff confirmed that the recommendation had not been implemented and that there was no clinical documentation indicating follow-up on the pharmacist's suggestion. The facility's policy required that all pharmacist-identified irregularities be acted upon according to established procedures, with urgent issues communicated to the DON or designee. In both cases, the facility did not follow through on the pharmacist's recommendations, resulting in the potential for unnecessary medication administration.
Unlabeled Pesto Sauce in Kitchen Freezer
Penalty
Summary
During an initial tour and observation of the facility kitchen, surveyors found a 22-ounce bottle of basil pesto sauce stored in the freezer with an unreadable best by or use by date. The Assistant confirmed that the date was not legible and acknowledged the importance of such dates for determining food safety and when to discard products. Review of the facility's policy indicated that all ready-to-eat, time/temperature control for safety foods must be clearly marked with a date to ensure they are consumed or discarded appropriately. The failure to maintain a readable date on the pesto sauce represented a lapse in adherence to the facility's food safety and date marking procedures.
Call Light Inaccessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident who required substantial to maximal assistance with personal hygiene, eating, and repositioning. The resident, who had diagnoses including diabetes mellitus and a fungal nail infection, was observed lying in bed with the call light wrapped outside of the left bedrail, making it inaccessible. The resident reported being unable to find or reach the call light. During the observation, a Licensed Vocational Nurse confirmed that the call light was not within easy reach and acknowledged that the resident needed help to access it. The facility's policy and procedure required staff to ensure call lights are within reach and secured as needed. This failure to follow policy resulted in the resident not having timely access to assistance.
Failure to Provide Communication Aid for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an effective communication method for a non-English speaking resident who preferred Vietnamese and was dependent on staff for activities of daily living. The resident had significant medical conditions, including diabetes mellitus, dysphagia, and a pressure ulcer, and was unable to understand or make herself understood in English. Observations revealed that there was no communication board at the resident's bedside, despite the care plan specifying the need for one due to the language barrier. Staff interviews confirmed the absence of a communication board and indicated reliance on a coworker for translation, who was not always available. The facility's policy required language assistance through various means, including bilingual staff, interpreters, or communication aids, but these were not provided in this case. The lack of an effective communication method had the potential to impact the resident's ability to express needs and receive necessary care and services. The deficiency was identified through observation, interviews with staff and the resident's responsible party, and review of the resident's records and facility policies.
Failure to Follow Physician's Order for Heel Offloading in Pressure Injury Care
Penalty
Summary
The facility failed to follow a physician's order to keep both heels of a resident free-floating, a technique intended to prevent pressure on the heels and promote healing of an existing pressure injury. The resident, who was admitted with diagnoses including diabetes mellitus, dysphagia, and a pressure-induced deep tissue injury of the right heel, was observed on multiple occasions lying in bed with both heels resting directly on the mattress. The resident was dependent on staff for all activities of daily living and had limited ability to communicate. Record review confirmed an active order to free float both heels using pillows, and staff interviews acknowledged the importance of this intervention for preventing new pressure injuries and supporting healing of the existing one. The facility's policy also required evidence-based interventions, such as offloading heels, for residents at risk or with pressure injuries. Despite these directives, the required intervention was not implemented as observed by surveyors.
Failure to Follow Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
Facility staff failed to follow physician orders for a resident who required hemodialysis four times a week and had a prescribed daily fluid restriction of 1200 ml. The physician's order specified that nursing staff were to provide 240 ml per day shift, 240 ml per evening shift, and 120 ml per night shift, totaling 600 ml, while dietary was to provide 200 ml for each meal, totaling another 600 ml. Upon review, there was no documentation in the resident's medical record regarding the restriction of fluid intake, and the Director of Nursing confirmed that there was no system in place to monitor the resident's daily fluid intake. The resident, who was cognitively intact and able to make decisions, reported that staff did not inform them of any fluid restrictions and that they typically drank as much as they wanted. The facility's policy required adherence to physician-ordered fluid restrictions, but this was not followed in practice for this resident, who had diagnoses including diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis.
Failure to Provide Arbitration Agreement in Resident's Preferred Language
Penalty
Summary
A deficiency occurred when a resident whose primary language was Spanish was presented with a binding arbitration agreement (AA) written in English during the admission process. The resident, who had diagnoses including atrial fibrillation, hypertension, and dependence on supplemental oxygen, was documented as having the capacity to understand and make decisions. The resident's preferred language was clearly indicated as Spanish in the Minimum Data Sheet, and both the resident and staff confirmed that the resident spoke and read only Spanish. Despite this, the Admission Director presented the AA in English and requested the resident's signature, without ensuring the resident understood the document. Interviews with facility staff, including the Admission Director and the Director of Nursing, confirmed that the AA was not explained or provided in a language the resident understood. The facility's policy required that such agreements be explained in a form and manner, including language, that the resident understands. The resident later stated they did not know what the AA meant, indicating the agreement was not fully understood at the time of signing.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that a multiple resident room in the Sub Acute Unit accommodated no more than four residents, as required. During the health recertification survey, it was observed that room [ROOM NUMBER] contained five beds, with four of them occupied by residents. The room also included side tables, a dresser, and resident care equipment. Staff reported that there was sufficient space to provide care and treatment, including for residents with ventilators, and that the room was large enough to accommodate the residents. The facility administrator confirmed that the room had more than four residents and stated that a waiver for six beds was being requested. Documentation reviewed indicated the room had 500.4 square feet and the waiver request asserted that the room's size and configuration did not compromise resident safety or care. However, at the time of the survey, the room was not in compliance with the regulation limiting occupancy to four residents per room.
Failure to Meet Minimum Room Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 9 of 28 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as observed during a health recertification survey. Specifically, rooms 16, 19, 20, 21, 22, 25, 26, 27, and 32 did not meet the square footage requirement. The deficiency was identified through observation, interviews with staff and residents, and review of facility records. The facility had not changed the number of beds in these rooms from the previous year and had submitted a waiver request for these rooms, indicating awareness of the space issue. Despite the deficiency, staff and residents reported that there was adequate space for movement and care activities, including the use of wheelchairs, walkers, and Hoyer lifts. Observations confirmed that residents could move freely and that staff could provide necessary care without difficulty. The facility's waiver request and client accommodation analysis stated that the room sizes did not adversely affect resident safety, care, or privacy, and that the needs of the residents were being met within the existing space.
Failure to Follow Hand Hygiene Protocols for C. difficile
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically regarding hand hygiene and the management of C. difficile infections. During an observation, a Licensed Vocational Nurse (LVN) was seen taking vital signs of a resident diagnosed with C. difficile without following proper handwashing procedures. After completing the task, the LVN used hand sanitizer instead of washing hands with soap and water, as required by the facility's policy for handling C. difficile cases. The LVN acknowledged the mistake, citing the resident's roommate's use of the restroom as the reason for not washing hands. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LVN should have waited to wash hands with soap and water to prevent the spread of infection. The facility's policies clearly state that handwashing with soap and water is mandatory for conditions involving C. difficile to prevent cross-contamination. The failure to adhere to these policies posed a risk of spreading the infection within the facility.
Failure to Maintain Safe Environment Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for Resident 1, as outlined in their policies and procedures. The Maintenance Director did not have a schedule for maintenance services for Resident 1's bed remote control coil line, which was damaged. This oversight led to the coil line being broken, with the outer hard plastic layer peeled off, exposing a sharp edge. This hazardous condition was not identified or addressed by the maintenance staff, as checking the bed remote control was not part of their routine tasks. During care, Certified Nurse Assistant 2 did not prevent Resident 1 from grabbing onto the damaged bed remote control coil line, which was hanging on the right bed side rail. As a result, Resident 1 sustained a laceration on the inner right hand between the thumb and index finger. The injury required medical attention, including seven surgical sutures for wound closure, and Resident 1 was transferred to a general acute care hospital for treatment. Resident 1 had a history of type II Diabetes Mellitus, heart failure, and respiratory failure, and was non-verbal with severely impaired cognition. The facility's failure to maintain equipment in good condition and provide adequate supervision during care directly contributed to the injury sustained by Resident 1. The incident highlights the importance of routine checks and maintenance of medical equipment to ensure resident safety.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to maintain the resident's bed remote control coil line in safe operating condition, resulting in a laceration on a resident's inner right hand. The resident, who was non-verbal and had severely impaired cognition, sustained a 2-centimeter laceration between the thumb and index finger due to the damaged hard plastic covering of the bed remote control coil line. The outer layer of the coil line was broken, exposing a sharp edge that caused the injury when the resident grabbed it during repositioning by a CNA. The Maintenance Assistant confirmed that checking the bed remote control was not part of the routine maintenance tasks and was only done upon request. This oversight led to the resident's injury, as the broken coil line was not identified and repaired in a timely manner. The Director of Nursing acknowledged the importance of routinely checking all medical devices and equipment to ensure they are in good condition for resident safety. The facility's preventive maintenance program policy indicated that a schedule of maintenance services should be developed to maintain equipment in a safe and operable manner.
Inadequate Infection Control Measures for Scabies
Penalty
Summary
The facility failed to maintain its infection control and prevention surveillance program for two residents, leading to a deficiency in infection control measures. Resident 1 was confirmed to have scabies following a positive skin scraping test. Despite this confirmation, the facility did not initiate a scabies line list immediately, as was done during a previous COVID outbreak. The Infection Preventionist (IPN) acknowledged that a line listing was not initiated until requested, and it was incomplete, lacking information on staff potentially exposed to Resident 1. The Director of Nursing (DON) was unaware of the need for a line listing and did not report the incident to the Public Health Department, considering it isolated. Resident 2 was identified as highly suspicious for scabies, yet infection control measures were not implemented. The resident had a generalized body rash, and treatment for scabies was initiated based on a dermatologist's assessment. However, there was no skin scraping to confirm the diagnosis, and the facility's staff did not clarify the suspicion of scabies with the dermatologist. The Treatment Nurse (TN) carried out orders for scabies treatment without informing the DON or confirming the suspicion of scabies. The Infection Prevention Nurse (IPN) noted that the facility's process required clarification of new orders for anti-scabies treatment, which was not done in this case. The facility's policy and procedure for infection control prevention surveillance were not followed, as evidenced by the lack of a line listing and failure to implement control measures for Resident 2. The local Public Health Guidelines for Scabies Prevention and Control were also not adhered to, as they require the preparation of a line listing for symptomatic patients and their contacts. The deficiency in infection control measures compromised the facility's ability to prevent the potential spread of infections.
Medication Mismanagement: Unattended Medication at Bedside
Penalty
Summary
The facility failed to adhere to professional standards of practice when a resident's medication was left unattended at the bedside. The resident, who was admitted with diagnoses including type 2 diabetes and Chronic Obstructive Pulmonary Disease, was found with two white capsules of Gabapentin in a clear plastic medicine cup on the bedside table. The resident stated that the medication was given by a licensed nurse earlier in the morning but was not taken immediately because the resident preferred to save it for later use when experiencing increased pain. The Director of Nursing confirmed that medications should not be left at the bedside and that licensed nursing staff are required to observe residents taking their medication at the time it is administered. This practice is crucial to ensure that residents actually take their medication as ordered, preventing potential complications and mismanagement of medical conditions. The facility's policy on medication administration mandates that staff observe resident consumption of medication and document any refusals.
Inadequate PPE Use in COVID-19 Isolation Room
Penalty
Summary
The facility failed to adhere to its infection control practices for Coronavirus Prevention and Response when a Certified Nursing Assistant (CNA) entered a COVID-19 isolation room without wearing the required Personal Protective Equipment (PPE). The incident involved Resident 5, who was placed under COVID-19 isolation due to exposure to a COVID-19 positive roommate. The CNA entered the room wearing only an N95 mask, despite signage indicating the need for full PPE, including a gown, gloves, face mask, and eye protection. This action was contrary to the facility's policy and the posted Novel Respiratory Precautions. Interviews conducted with the CNA and the Infection Preventionist Nurse (IPN) confirmed the requirement for full PPE when entering isolation rooms. The CNA acknowledged the need for full PPE to prevent the spread of COVID-19, and the IPN reiterated that all staff must comply with these precautions. Resident 5 was aware of the COVID-19 status of their roommate and the necessity for staff to wear protective equipment. The facility's policy, dated 2022, clearly outlined the PPE requirements for healthcare personnel entering rooms of residents with suspected or confirmed SARS-CoV-2 infection.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to adhere to its policy and procedure for nail care for a resident with contractures in both hands. The resident, who was admitted with diagnoses including contracture of the hands, functional quadriplegia, and chronic respiratory failure, was observed to have long and overgrown fingernails and toenails with a brown substance underneath. The resident's care plan indicated a need for assistance with activities of daily living due to physical limitations, yet the necessary nail care was not provided. Certified Nursing Assistants (CNAs) did not trim or clean the resident's fingernails, nor did they notify Licensed Vocational Nurses (LVNs) about the overgrown toenails. The LVNs also failed to inform the Social Services Director (SSD) to arrange for a podiatrist to address the toenail issue. Observations and interviews with staff confirmed that the resident's nails were long, dirty, and posed a risk of injury and infection, particularly given the resident's contracted hands. The Director of Nursing (DON) stated that residents' nails should be assessed daily and maintained as part of ADL care. However, the facility's policy, which required regular nail care and assessments, was not followed. This oversight had the potential to cause harm to the resident, as the long nails could lead to cuts, scrapes, and infections.
Failure to Provide Reasonable Accommodation of Needs for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents, Resident 270 and Resident 2. Resident 270, who was admitted with myotonic muscular dystrophy, contractures, and dependence on a ventilator, was unable to use the call light due to his inability to move his arms and hands. Despite being alert and able to communicate his needs, the call light was pinned behind his head and out of reach. Staff interviews revealed that alternative call light options were available but were not provided to Resident 270, leading to his inability to notify staff for assistance, including critical needs like suctioning his trach tube. Resident 2, who had a history of falls and was assessed as high risk for falls, also experienced a failure in accommodation. The resident's care plan indicated that the call light should be within reach due to his severe cognitive impairment and dependence on staff for daily activities. However, during an observation, the call light was found hanging on the siderails and covered with a pillow, making it inaccessible. Staff interviews confirmed that the call light should have been within the resident's reach to ensure safety and timely assistance. The facility's policies and procedures on call light accessibility and accommodation of needs were not followed in both cases. The policies required staff to evaluate and provide special accommodations for residents' unique needs, but this was not done for Resident 270 and Resident 2. This failure had the potential to result in both residents being unable to notify staff for their needs and possibly in emergencies.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for two residents, leading to potential treatment and services being administered against their will. Resident 45 was admitted with type 2 diabetes mellitus and had fluctuating capacity to understand and make decisions. Despite this, the AD Acknowledgement Form for Resident 45 was not completed. Interviews with the Assistant Social Service Director (ASSD) and the Assistant Director of Nursing (ADON) confirmed that the form needed to be filled out completely, and it was the resident's right to formulate an AD upon admission to ensure care and treatment aligned with their wishes. Similarly, Resident 47, who was admitted with hypertension and had moderately impaired cognition, did not have an AD assessment performed. The ASSD confirmed that there was no documentation indicating that AD information was offered to Resident 47 or their Responsible Party. The facility's policy required that AD information be documented upon admission to provide care and treatment according to the resident's wishes. The failure to follow this policy was confirmed through interviews and record reviews.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for the residents' suprapubic and indwelling catheters as ordered by the physician and indicated in the residents' care plans. Resident 15, who had diagnoses including hydroureter, chronic kidney disease, and urinary retention, was observed with an indwelling catheter that was not connected to a stabilization device, posing a risk of catheter-related trauma. The Licensed Vocational Nurse (LVN) confirmed that the catheter tubing needed to be connected to the stabilization device to prevent injury or trauma to the urethra. Resident 11, diagnosed with neuromuscular dysfunction of the bladder and urinary tract infections, was observed with a suprapubic catheter that was not covered with a dressing and was not secured with a stabilization device. The resident was seen touching the catheter site, which increased the risk of infection. The LVN and the Infection Preventionist Nurse (IPN) both stated that the catheter site needed to be covered and the tubing secured to prevent pulling, dislodgement, and infection. The Assistant Director of Nursing (ADON) confirmed that the catheter stabilization device is essential to prevent accidental pulling, injury, trauma, and possible hospitalization. The facility's policy and procedure on indwelling catheter use and removal emphasized the importance of keeping the catheter anchored to prevent excessive tension, urethral tears, or dislodgement, and ensuring the catheter is positioned below the level of the bladder to facilitate urine flow and prevent kinks in the tubing.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to follow its Policy and Procedure (P&P) for enteral feeding for two residents. For Resident 2, the gastrostomy tube (G-tube) dressing was not changed per protocol. The resident's care plan indicated the need for daily dressing changes to prevent infection, but during an observation, the dressing was found to be loose, dirty, and dated three days prior. Staff interviews confirmed that the dressing should be changed daily as ordered by the physician to prevent infection, but this was not done as documented in the Treatment Administration Record (TAR). The facility's P&P also required documentation of the procedure, which was not properly followed in this case. For Resident 274, the facility failed to ensure proper positioning during enteral feeding. The resident was observed lying flat on the bed while the feeding was ongoing, contrary to the care plan that required the head of the bed to be elevated between 30 to 45 degrees during feeding. Staff interviews revealed that the enteral feeding should be paused when changing the resident's linens or clothing to prevent aspiration, but this protocol was not followed. The facility's P&P indicated that the resident's plan of care should direct staff regarding proper positioning, which was not adhered to in this instance. These failures had the potential to cause infection for Resident 2 and the risk of aspiration for Resident 274. The facility's policies and procedures were not followed, leading to these deficiencies. Staff interviews and record reviews confirmed that the required care and documentation were not consistently provided, highlighting lapses in adherence to established protocols for enteral feeding and gastrostomy site care.
Failure to Ensure Proper Respiratory Care and Safety
Penalty
Summary
The facility failed to ensure proper respiratory care and resident safety for two residents receiving oxygen therapy. For Resident 30, who was admitted with a history of falling and Chronic Obstructive Pulmonary Disease (COPD), the nasal cannula tubing was observed to be rolled and inserted into the handle of the oxygen concentrator instead of being stored in a plastic bag when not in use. This was confirmed by the Director of Staff and Development (DSD) and the Assistant Director of Nursing (ADON), who both stated that the nasal cannula tubing should be stored in a plastic bag to prevent infection and cross-contamination. The facility's policy on Oxygen Administration also indicated that oxygen tubing and masks or cannulas should be kept covered in a plastic bag when not in use. For Resident 274, who was ventilator-dependent and had fluctuating capacity to understand and make decisions, there was no spare tracheostomy tube readily available at the bedside. This was observed and confirmed by Respiratory Therapist 2 (RT 2) and the Respiratory Supervisor (RT Sup), who stated that an emergency trach tube needed to be easily accessible at the bedside to maintain a patent airway during an emergency. The facility's policy on Sudden Respiratory Distress Differential Diagnosis also indicated that emergency airway management supplies, including a replacement trach tube, should be at the resident's bedside or within close proximity.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing bed rails for two residents, both diagnosed with dementia and epilepsy. Resident 17 was admitted on 3/2/2023 and was observed on 4/9/2024 with both upper siderails up. The bedrail assessment for Resident 17 indicated that alternatives such as lowering the bed and using pillows were attempted but did not specify how these alternatives failed. The MDS Nurse Coordinator mentioned that other alternatives like bolsters or bumpers could have been used, which was confirmed by the Director of Nursing (DON). However, these alternatives were not documented as attempted in the resident's assessment records. Similarly, Resident 170, admitted on 10/12/2023, was also found to have bed rails installed without sufficient documentation of failed alternatives. The assessment for Resident 170 only mentioned the use of pillows as an alternative but did not explain their ineffectiveness. The DON confirmed that bolsters or bumpers were available but not documented as attempted alternatives in the resident's records. The facility's policy requires a person-centered approach and the use of appropriate alternatives before installing bed rails, which was not followed in these cases.
Infection Control Deficiencies in Wound Care, Curtain Changes, and PPE Use
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections for five sampled residents. Specifically, the facility did not ensure that wound care for Resident 35 was performed in a manner that would prevent the introduction of potentially contaminated material into the wound. During an observation, LVN 7 used a disposable measuring guide stored without any cover to measure the wound, which was against the facility's policy that required sterile or clean instruments for wound care. The Infection Prevention Nurse confirmed that the measuring guide should not have been used as it could be contaminated, and the facility's policy indicated that wound care should be provided to decrease potential for infection and cross-contamination. Resident 35 had moderate cognitive impairment and required assistance with personal care, making proper wound care essential for their health and safety. The facility also failed to change curtains during deep cleaning for two residents, Resident 8 and Resident 61, out of 28 rooms. Resident 8, who had enterocolitis due to clostridium difficile and a history of urinary tract infections, reported that the curtains had not been changed since admission. Similarly, Resident 61, who had type 2 diabetes mellitus and chronic obstructive pulmonary disease, stated that the curtains in their room had not been changed since admission. The Housekeeping Supervisor confirmed that curtains should be changed during deep cleaning to prevent the spread of infections, but the facility's policy did not specify the frequency for changing curtains. The Infection Prevention Nurse emphasized that curtains are highly touched areas and should be changed to prevent infection spread. Additionally, the facility did not ensure proper hand hygiene and glove use by staff. The Infection Prevention Nurse did not change gloves or perform hand hygiene after touching Resident 42's indwelling catheter before touching the resident's breathing treatment mask and tube. Resident 42 had severely impaired cognition and required total dependence on staff for daily activities. The Assistant Director of Nursing confirmed that staff needed to change gloves and perform hand hygiene before and after touching contaminated equipment. Furthermore, the Nurse Practitioner did not wear the required PPE while performing a physical assessment on Resident 274, who was on Enhanced Barrier Precaution due to the presence of medical devices and chronic wounds. The Infection Preventionist and Medical Director confirmed that proper PPE was necessary to prevent the transmission of multidrug-resistant organisms.
Failure to Implement Comprehensive Care Plan for Resident with Multiple Pressure Injuries
Penalty
Summary
The facility failed to initiate and implement a care plan for a resident (Resident 274) who had multiple pressure injuries (PIs) upon admission. The resident was admitted with several PIs, including unstageable PIs on the sacral region, right and left buttocks, right ankle, right heel, and other areas. Despite having a high risk for developing pressure injuries as indicated by the Braden Scale, the facility did not create a comprehensive care plan for all of the resident's PIs. This omission was confirmed during interviews with the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RN Sup), who acknowledged that the care plan should have included all PIs to ensure proper treatment and monitoring. The resident's medical history included dependence on a ventilator, a gastrostomy tube, and a tracheostomy tube, which further complicated their condition. The facility's records showed that there were active medical orders to treat the PIs, but these were not reflected in a comprehensive care plan. The LVN and RN Sup both stated that the absence of a care plan for each PI could lead to worsening conditions or infections, as staff would not be aware of the specific interventions required for each injury. The Assistant Director of Nursing (ADON) also confirmed that the charge nurse was responsible for initiating the care plan and that it should have been completed upon admission. The facility's policies and procedures indicated that care plans should include measurable objectives and timeframes to meet the resident's needs, and should be updated as necessary. However, the failure to list each PI in the care plan put the resident at risk of their injuries worsening due to lack of proper treatment and monitoring.
Failure to Provide Communication Aid for Resident with Tracheostomy
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy and chronic respiratory failure was provided with a Passy-Muir Valve (PMV) for effective communication. The resident, who was dependent on staff for various activities of daily living, had unclear speech and limited ability to make self-understood. Despite having a physician's order for the PMV, the staff did not utilize the device, leading to communication difficulties. The resident's care plan indicated the need for communication aids, but the staff were unaware of the PMV's availability and its use for the resident's communication needs. During observations and interviews, it was found that the resident's PMV was stored in a drawer and not used by the staff. Licensed nurses and a respiratory therapist confirmed that they were trained to apply the PMV, but the device was not utilized to assist the resident in communicating effectively. The facility's policy stated that the PMV should be provided to the resident with a physician's order and applied by trained staff, but this was not followed, resulting in the resident's unmet communication needs.
Failure to Follow Pressure Injury Prevention Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for pressure injury prevention for Resident 274. Despite having an active medical doctor's order for bilateral heel protectors to manage multiple pressure injuries, the protectors were not observed on the resident during an inspection. Resident 274 had several pressure injuries, including unstageable pressure injuries on the left lateral mid foot, left medial foot, left medial malleolus, right lateral malleolus, and right lateral mid foot, as well as deep tissue injuries on the right heel and lower back. The resident was also at high risk for developing new pressure injuries, as indicated by a Braden Scale assessment. Interviews with staff, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Assistant Director of Nursing, confirmed that the heel protectors were not applied as ordered, which could potentially worsen the resident's existing pressure injuries or lead to new ones. The facility's policies on skin integrity foot care and pressure injury prevention and management were reviewed and indicated that appropriate offloading devices and evidence-based interventions should be implemented for residents at risk of pressure injuries. Despite these policies, the facility did not adhere to the medical doctor's order for bilateral heel protectors for Resident 274, leading to a failure in pressure injury prevention and management. This oversight was confirmed through observations, interviews, and record reviews, highlighting a significant lapse in the facility's adherence to its own protocols and procedures for wound management and pressure injury prevention.
Failure to Adhere to Turning and Repositioning Schedule for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services for a resident with pressure ulcers by not adhering to the prescribed turning and repositioning schedule. The resident, who had severe cognitive impairment and was totally dependent on staff for daily activities, was observed to have been left in the same position for extended periods, contrary to the facility's policy of turning and repositioning every two hours. This was confirmed through multiple observations and interviews with staff, as well as a review of the resident's care plan and turning and repositioning log. The resident had multiple stage 4 pressure ulcers and was at high risk for further skin breakdown. Despite the facility's policy and the resident's care plan indicating the need for frequent repositioning, the resident was not turned and repositioned as required. This lapse in care was observed on several occasions, including during the resident's dialysis days when the resident was out of the facility for extended periods. Staff interviews corroborated that the turning and repositioning schedule was not consistently followed, leading to the potential for further skin damage and delayed wound healing.
Failure to Maintain and Properly Apply Hand Splint
Penalty
Summary
The facility failed to ensure that a resident's right-hand splint was maintained and properly applied in accordance with the facility's policy and procedure. The resident, who had diagnoses including muscle wasting and contracture of both hands, was on a Restorative Nursing Program to address potential decline in range of motion. The care plan required staff to apply wrist and hand splints to the resident's right and left wrist/hand for four hours daily, five times a week, or as tolerated. However, during an observation, the splint on the resident's right wrist/hand was found not connected and was observed on the resident's bed, indicating non-compliance with the care plan and facility policy. Interviews with the Licensed Vocational Nurse, Restorative Nurse Assistant, and Assistant Director of Nursing confirmed that the splints needed to be kept in place as scheduled to prevent further contracture and maintain mobility. The facility's policy on Restorative Nursing Programs indicated that residents identified during a comprehensive assessment process would receive services from restorative aides, including splint or brace assistance. The failure to ensure the proper application and maintenance of the splint placed the resident at risk for contractures and potential decline in physical function.
Failure to Follow Hoyer Lift Policy and Procedure
Penalty
Summary
The facility failed to supervise and follow policy and procedure for the use of a Hoyer Lift, a mechanical device that requires two staff members to operate, for Resident 274. During an observation, it was noted that a Certified Nurse Assistant (CNA) operated the Hoyer Lift alone, lifting Resident 274 from the bed and leaving the resident suspended in the air unsupervised while the CNA walked away to close the curtain. This action was against the facility's policy, which mandates that two staff members must be present during the operation of the Hoyer Lift to ensure the resident's safety. Resident 274 had multiple medical conditions, including pressure injuries, dependence on a ventilator, and a gastrostomy tube, which required careful handling. The resident's care plan indicated the need for assistance from two or more persons for transfers. Despite this, the CNA proceeded to use the Hoyer Lift alone, and the Licensed Vocational Nurse (LVN) present was occupied with other tasks and not available to assist. This left Resident 274 at risk of falling and sustaining serious injury. Interviews with the CNA, LVN, Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that the facility's policy requires two staff members to be present during the use of the Hoyer Lift. The ADON and DSD emphasized the importance of this policy to prevent accidents and ensure resident safety. The facility's policy and the manufacturer's instructions both clearly state that residents should never be left unattended during lifting, highlighting the severity of the deficiency in this incident.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate supervision or assistance during meals for a resident with severe cognitive impairment and Parkinson's disease, leading to potential further weight loss. The resident, admitted with diagnoses including dementia and Parkinson's disease, required supervision or touching assistance with eating due to severe cognitive impairment and functional limitations in both upper and lower extremities. Observations revealed that the resident struggled to eat independently due to noticeable tremors and was often left unattended during meals, resulting in most of her food being untouched and her nutritional supplement unopened. On multiple occasions, staff failed to provide the necessary assistance. For instance, during one observation, the resident was seen holding a coffee cup with tremors and unable to eat her meal, which remained untouched. The dietary supervisor and nursing assistants did not intervene or assist the resident adequately. Interviews with staff indicated a lack of familiarity with the resident's needs and inconsistent documentation regarding the level of assistance required. The resident expressed that she would eat more if assisted, highlighting the impact of her tremors on her ability to feed herself. The resident's weight log showed a significant decline from 162 pounds to 133 pounds over several months, indicating ongoing nutritional issues. The care plan and nutritional assessments noted the need for monitoring and encouragement to eat, but these interventions were not effectively implemented. The facility's policies on weight management and meal supervision were not followed, contributing to the resident's inadequate nutrition and weight loss.
Failure to Label and Date Midline Intravenous Catheter
Penalty
Summary
The facility failed to label and date the midline intravenous catheter for Resident 45, which was necessary for infection control. Resident 45 was admitted with type 2 diabetes mellitus and hyperglycemia and had fluctuating capacity to understand and make decisions. The resident's care plan required the dressing of the midline catheter to be changed every seven days and labeled with the date, time, and initials of the licensed nurse. However, during an observation, it was found that the midline intravenous site was not dated, which was confirmed by the Infection Preventionist Nurse. The Assistant Director of Nursing confirmed that the IV site should be labeled to prevent infection. The facility's policy on Peripheral Intravenous Catheter Insertion, Maintenance, and Removal also indicated that the dressing should be labeled with the date, time, and initials. The failure to follow this policy had the potential to result in an infection for Resident 45, who had moderately impaired cognition and required total dependence on staff for activities of daily living.
Inaccurate MDS Assessments for Discharge Destinations
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the discharge destinations for two residents. Resident 68, who was discharged to a Skilled Nursing Facility (SNF), was incorrectly coded in the MDS assessment as being discharged to home. This discrepancy was confirmed during an interview with the facility's Minimum Data Set Nurse (MDSN), who acknowledged the error and emphasized the importance of accurate coding for providing correct information to the Centers for Medicare and Medicaid Services (CMS). Resident 68's admission record and physician's order both indicated a transfer to a SNF, contradicting the MDS assessment's coding of discharge to home. Similarly, Resident 67, who was discharged to home with home health services, was inaccurately coded in the MDS assessment as being discharged to a General Acute Care Hospital (GACH). This error was confirmed through a review of Resident 67's admission record, physician's order, post-discharge plan of care, and progress notes, all of which indicated a discharge to home. Interviews with the MDS coordinator and the Director of Nursing (DON) further confirmed the inaccuracy, highlighting the necessity of accurate MDS assessments for the continuation of care and accurate reporting to CMS. The facility's policy on conducting accurate resident assessments, revised in December 2022, was not adhered to in these instances.
Room Exceeding Resident Capacity
Penalty
Summary
The facility failed to ensure that one of its resident rooms accommodated no more than four residents, as required by regulations. Specifically, room [ROOM NUMBER] in the Sub Acute Unit had five beds, with four of them occupied by residents. This was confirmed during an entrance conference with the facility Administrator, who acknowledged the situation and mentioned that the facility would continue to request a room waiver for this room. Observations during the Health Recertification Survey showed that the room contained beds, side tables, dressers, and resident care equipment, and staff were able to move freely within the room. However, the room still exceeded the maximum allowed number of residents per room, which could lead to privacy concerns and crowded conditions. Licensed Vocational Nurse 6 also confirmed the presence of five beds in the room and stated that there was enough space to provide care and treatment, including for residents with ventilators, without issues. The facility had submitted a room waiver request indicating that the room's 494 square footage was adequate for the residents' special needs and did not compromise their health and safety or the care provided. The deficiency was identified during the Health Recertification Survey conducted from 4/9/2024 to 4/12/2024. The facility's letter requesting a room waiver, dated 4/9/2024, stated that the room's size and configuration were in accordance with the special needs of the residents and did not adversely affect their health and safety. Despite this, the room still did not comply with the regulatory requirement of accommodating no more than four residents, leading to the identification of this deficiency. The facility's actions and inactions in maintaining more than the allowed number of residents in a single room were the primary factors leading to this deficiency.
Failure to Meet Square Footage Requirements in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 14 of 28 rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. The rooms in question were Rooms 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27, 32, 33, and 35. During the Health Recertification Survey, it was observed that these rooms did not meet the required square footage per resident. Despite this, the facility's Administrator stated that a room waiver would be requested for these rooms, indicating that the current room sizes did not adversely affect the health, safety, or care of the residents. The facility's letter requesting the waiver and the Client Accommodations Analysis supported this claim, stating that the residents' safety and care were not compromised by the existing room sizes. Interviews with staff and residents corroborated that there was enough space to provide care and that the room sizes did not impede the movement of wheelchairs and walkers or the provision of nursing care and treatments, including for residents with ventilators. During interviews, both a Certified Nurse Assistant and a Licensed Vocational Nurse confirmed that there was sufficient space in the rooms to provide care and move equipment without issues. Additionally, a resident who used a wheelchair stated that he could move freely in and out of his room without any concerns. Observations during the survey also indicated that residents had adequate space to move freely inside the rooms, and each resident had beds and bedside tables with drawers. The room sizes did not affect the care and services provided to the residents when nursing staff were observed providing care. Despite the facility's efforts to justify the room sizes, the deficiency was noted due to the failure to meet the regulatory square footage requirements per resident in multiple resident rooms.
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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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