Sunset Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 2250 29th Street, Santa Monica, California 90405
- CMS Provider Number
- 055748
- Inspections on file
- 39
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sunset Park Healthcare during CMS and state inspections, most recent first.
A resident with dementia and Alzheimer’s disease, who had severely impaired cognition and required assistance with ADLs, gave an LVN access to a credit card to purchase a cell phone. Over several days, multiple unauthorized charges appeared on the card, including personal purchases at a beauty provider, hotel reservations in another state, and dry cleaning far from the facility. The resident reported not authorizing these expenditures and was upset that someone accessed his wallet and took the card. Another LVN described it as unusual that a charge nurse repeatedly insisted on escorting the resident to the bank, given ongoing staff education not to accept money or gifts from residents. The involved LVN admitted using the resident’s card, including for a hotel reservation, and not promptly returning it, despite having completed abuse prevention and gifts/gratuities training that prohibited misappropriation of resident funds.
A resident with epilepsy, Alzheimer's disease, severe cognitive impairment, high fall risk, and total dependence for ADLs was not provided the documented two-person assist for mobility and transfers as indicated on the MDS and therapy assessments. While being given a shower, the resident slipped on the floor, and afterward was not evaluated or assessed by an RN/LPN in accordance with the facility’s fall clinical protocols and fall risk management policies.
Surveyors found that three residents with cognitive and physical impairments did not have functioning call devices within reach, as required by their care plans and facility policy. One resident was given a table bell as an alternative, while the others had no way to alert staff for assistance due to a malfunctioning call light system.
A resident with severe cognitive impairment and a history of respiratory and mental health conditions was not permitted to receive visitors of their choosing due to restrictions imposed by a family member, despite facility policy and regulations prohibiting such limitations unless there is immediate risk. Staff enforced these restrictions, and no care plan was developed to address the family conflict or visitation issue.
A facility failed to create a comprehensive care plan addressing a resident's visitation rights and ongoing family conflict, despite the resident's impaired cognition and documented disputes among family members. Staff and documentation confirmed that no care plan was developed to manage the situation, contrary to facility policy and regulatory requirements.
The facility did not develop or implement comprehensive care plans for several residents with severe cognitive impairment and complex needs. One resident was placed at risk of entrapment due to improper bed and bedside table placement, while two other residents with behavioral and mobility issues lacked care plans addressing their specific risks. Staff and DON confirmed these omissions, which were not in accordance with facility policy.
A resident with severe hearing loss did not receive timely hearing aids or alternative communication tools, despite documented need and care plan interventions. The resident experienced frustration, difficulty communicating with staff, and inability to watch TV, while staff were unaware of the hearing aid issues and did not follow facility policies for supporting hearing-impaired residents.
Three residents with severe cognitive and physical impairments did not consistently receive physician-ordered restorative nursing treatments, including PROM exercises and use of splints, as required by facility policy. Documentation of these treatments was completed in advance rather than reflecting actual care provided, as confirmed by staff interviews and record review. This failure resulted in a deficiency related to the maintenance and improvement of residents' range of motion.
A resident with dysphagia and cognitive impairment, fully dependent on staff, was found to have multiple broken, missing, and discolored teeth and had not received dental care since admission, despite physician orders and facility policy requiring regular dental services. Staff confirmed the absence of dental records and acknowledged the expectation for routine dental exams.
A dietary staff member failed to use proper measuring utensils when preparing Paprika Beef, instead scooping bouillon powder with a spoon and not following the facility's recipe. The staff member, new to the facility, admitted to not following recipe protocols, and the Dietary Supervisor confirmed that all cooks are required to use measuring utensils and follow recipes to ensure proper meal preparation.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including expired and unlabeled food items, improper storage of staff personal items in resident refrigerators, unclean utensils and surfaces, and failure to dispose of expired foods. Dietary staff were unaware of proper storage times, and facility policies for labeling and monitoring food were not followed.
A CNA was observed wearing the same gown, mask, and gloves while providing care to three residents on Enhanced Barrier Precautions, including checking gastrostomy tube sites, without changing PPE or performing hand hygiene between each resident. All three residents were severely cognitively impaired, totally dependent for ADLs, and had physician orders for EBP. Facility policy and the DON confirmed that PPE should be changed and hand hygiene performed between residents to prevent cross-contamination.
A leaking pipe under the kitchen sink was left unrepaired for about one to two weeks, with staff using a bucket to catch the water. Dietary and maintenance staff were aware of the issue, but there was a delay in repair and inconsistent reporting of when the maintenance supervisor was notified. Additionally, required maintenance repair logs and schedules were not maintained as per facility policy.
Nine rooms did not meet the required 80 sq. ft. per resident, with some rooms providing only 75.3 or 77.6 sq. ft. per resident. A resident with multiple chronic conditions was unable to move freely in her room due to the placement of a bariatric bed and bedside table, which further restricted access to the bathroom and safe movement.
A resident with severe cognitive impairment and multiple diagnoses was administered psychotropic medications without complete or signed informed consent forms from the resident or responsible party. Staff confirmed that required documentation was missing, and facility policy mandating written consent prior to administration was not followed.
A bariatric bed and bedside table in a shared room created a crowded environment, limiting a resident's ability to move freely and safely access the bathroom. The resident, who required assistance with mobility and daily activities, reported feeling confined and unable to move around the room without difficulty.
A resident with severe cognitive impairment and total dependence on staff had multiple personal belongings go missing after admission. The facility did not complete an inventory of the resident's property at admission as required by policy, and family reports of missing items were not addressed or resolved by staff.
A resident with severe cognitive impairment and total dependence for ADLs was unnecessarily restrained when a low, sagging bed and a bedside table blocked their ability to get out of bed. Staff confirmed these measures were used to prevent falls, contrary to facility policy, and both the LVN and DON acknowledged that these practices restricted the resident's movement and posed a risk of entrapment.
The facility did not complete required background checks and screenings for two newly hired nurses with direct resident access, as confirmed by staff interviews and review of personnel files. This failure to follow policy placed all residents at risk, especially due to the presence of controlled medications.
A resident with severe cognitive impairment and a tendency to place objects in his mouth was found with hazardous items like cleanser bottles and razors accessible at his bedside, despite staff awareness of his behavior. Another resident with confusion and wandering behaviors was not properly assessed for elopement risk, lacked an appropriate care plan, and required constant supervision. These deficiencies in supervision, environmental safety, and risk assessment increased the risk of injury and accidents.
Staff did not label the open date on foil pouches containing inhalation medications for two residents with severe cognitive impairment and chronic respiratory conditions. During a medication cart inspection, opened pouches of ipratropium-albuterol and albuterol solutions were found without date labels, despite manufacturer instructions requiring use within a set period after opening. The DON and an LVN confirmed that the medications should have been dated according to policy and manufacturer guidelines.
A resident with severe cognitive impairment and total dependence on staff was found with diclofenac cream accessible at bedside, despite not being approved for self-administration. Additionally, a pill cutter on a medication cart was observed to be unclean, with visible residue, contrary to infection control protocols. Staff confirmed these practices did not follow facility policy for medication storage and equipment sanitation.
Surveyors found that two residents were served overcooked and unpalatable food, including hard pork chops and dinner rolls, leading them to request alternative meals. Both residents reported dissatisfaction with the food quality, and one was unable to eat the pork chop due to dental issues. The Dietary Supervisor confirmed the overcooking of the meal components.
A resident with dysphagia, metabolic encephalopathy, and a gastrostomy, requiring 100% feeding assistance and aspiration precautions, was left with another resident's breakfast tray within reach and without staff supervision. Staff interviews revealed a lack of awareness about the incident and the associated risks, and facility policy requiring tray verification was not followed.
A resident with diabetes and other medical conditions did not receive their physician-ordered fortified CCHO diet with double protein portions for breakfast and dinner. The resident's breakfast tray was found on another resident's table, and staff were unaware of the error. Facility policies requiring correct tray identification and timely meal service were not followed, resulting in the resident missing their prescribed meal.
Two residents with significant medical needs and varying cognitive abilities experienced repeated delays in staff response to call lights, sometimes waiting over 30 minutes for assistance with ADLs such as toileting and changing briefs. Both residents expressed anger over these delays. Staff interviews confirmed that call lights are expected to be answered within 3 to 5 minutes, and facility policy requires prompt response.
Facility staff failed to prevent waste equipment from overflowing in the waste disposal area, resulting in garbage spilling onto the ground. A maintenance staff member was observed standing on top of the trash bin to press down the waste, and both the maintenance staff and DON acknowledged that this situation posed environmental and safety hazards, including exposure to pests and infectious diseases. Facility policies requiring a clean, safe, and orderly environment were not followed.
Two resident rooms were found to contain six beds each, exceeding the federal limit of four residents per room. Despite facility documentation and observations indicating sufficient space and freedom of movement for residents and staff, the rooms did not comply with occupancy regulations.
A resident with severe cognitive impairment and a diagnosis of TB repeatedly refused prescribed TB medications, but the facility did not document physician notification of these refusals as required by policy. Staff interviews confirmed that refusals were not consistently reported or recorded in the resident's medical record.
A resident with severe cognitive impairment and major depressive disorder was prescribed mirtazapine, but the required informed consent documentation was incomplete, lacking a physician's signature and proper witness dating. Facility staff confirmed that this did not meet policy requirements for informed consent prior to administering psychotropic medication.
Two residents with cognitive and physical impairments were involved in altercations that were witnessed and documented by staff, but the incidents were not reported to the State Agency or properly documented according to facility policy. Internal investigations lacked documentation, and required notifications to authorities were not made, resulting in delayed external review.
Two residents with significant cognitive and physical impairments were involved in repeated verbal and physical altercations, which were witnessed and documented by staff. Despite this, there was no evidence of a formal investigation or required reporting to authorities, as mandated by facility policy. The DON acknowledged the incidents but could not provide documentation of any investigation or outcome.
A facility failed to properly label and dispose of enteral feeding bottles for a resident, leading to a deficiency. The feeding bottle lacked an infusion start time and was used beyond the 48-hour limit, contrary to guidelines. The DON confirmed that this oversight could lead to pathogen growth and foodborne illness risk.
A resident with COPD and other conditions was observed receiving 5 liters per minute of oxygen instead of the prescribed 2 liters per minute. The LVN could not explain the deviation, and the DON acknowledged the risk of oxygen overdose. The facility's policy specifies oxygen administration at 2 to 3 liters per minute unless otherwise ordered.
A resident in an LTC facility was administered a medication that had fallen onto the floor, contrary to the facility's infection control policy. The resident, with medical conditions including diabetes and hypertension, was given Ativan by an LVN who acknowledged the facility's policy to discard contaminated pills. The DON confirmed the policy, highlighting the risk of administering soiled medication.
A resident with cognitive impairment was verbally abused by an LVN, who admitted to cursing at the resident during an altercation. The incident was documented, and the LVN was terminated for violating the facility's abuse prevention policy.
A resident was transferred from SNF1 to SNF2 without prior notification to the resident or their representative, resulting in aggressive behavior at SNF2. The resident, with a history of encephalopathy, psychosis, depression, and anxiety, exhibited volatile actions, including throwing objects and invading personal space. Staff attempts to manage the situation were unsuccessful, and the resident was returned to SNF1 the same day.
The facility failed to ensure safe food handling practices as Cook 1 was observed not wearing a hairnet and gloves while preparing food for residents. Interviews with the DSS and DON confirmed the requirement for staff to wear protective gear and wash hands before entering the kitchen. The facility's policy also emphasized avoiding bare hand contact with food. This oversight risked harmful bacteria growth and cross-contamination, potentially affecting 41 medically compromised residents.
The facility was found non-compliant with regulations by housing six residents in two rooms, exceeding the allowed capacity of four. Despite residents expressing satisfaction with the space and care, the room configuration did not meet regulatory standards. A waiver request was submitted, noting the rooms' spaciousness and privacy provisions.
The facility did not meet federal regulations for room size, with ten out of thirteen rooms failing to provide the required 80 square feet per resident. Despite this, observations and resident interviews indicated sufficient space for movement and care. A waiver request was submitted, and the Department recommended its continuation.
Failure to Protect Resident From Financial Abuse by LVN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial abuse and misappropriation of property by a staff member, contrary to its abuse prevention and gifts/gratuities policies. The resident was admitted with dementia and Alzheimer’s disease and had severely impaired cognition per the most recent MDS, requiring assistance with activities of daily living and using a wheelchair. The resident had both a debit and a credit card. Over a period in February, multiple charges appeared on the resident’s credit card, including purchases at a beauty enhancement provider, two small charges to an individual, two hotel charges in Las Vegas, and a dry-cleaning purchase located 34 miles from the facility. The resident did not authorize these purchases. In interviews, the resident stated that an LVN had been his nurse for several months, had brought him clothing, and had accompanied him to the bank four or five times. The resident reported giving the LVN his credit card to purchase a new cell phone, which the LVN said she would obtain for him. The resident later learned from facility staff, after they reviewed his bank statements, that the LVN had used his credit card for unauthorized purchases. The resident stated that he did not give the LVN permission to use his card for a trip to Las Vegas or for other personal expenses, and that he was upset that someone had accessed his wallet and taken the credit card. He also stated that the LVN never gave him the cell phone at the time, and that a cell phone arrived several days after the incident came to light. Another LVN reported that it was unusual for a charge nurse to insist on escorting a resident to the bank, noting that escorts were typically provided by activities staff or CNAs and that staff were regularly in-serviced not to accept money or gifts from residents because it could be considered financial abuse. In a phone interview, the LVN involved acknowledged escorting the resident to open a bank account after work, paying for transportation, and buying cigarettes for the resident. She stated that the resident insisted on giving her his card so she could buy items he wanted, including a phone and organizer, and admitted she did not promptly return the card. She further admitted using the resident’s credit card to reserve a hotel and stated she did not remember telling the resident about this use or the amount spent. The discharge planner discovered suspicious charges when assisting the resident with a call to his bank, and the administrator confirmed with the resident that he had not authorized the purchases. Facility records showed that the LVN had previously completed abuse prohibition training and signed acknowledgments of the abuse and gifts/gratuities policies, which define misappropriation and financial abuse as wrongful use of a resident’s money without consent and prohibit employees from accepting or giving anything of value to or from residents.
Failure to Provide Required Two-Person Assist and Post-Fall Nursing Assessment
Penalty
Summary
Surveyors identified a deficiency in accident prevention and supervision related to one resident with significant cognitive and functional impairments. The resident had diagnoses including epilepsy, muscle weakness, gait and mobility abnormalities, and Alzheimer's disease, and the MDS documented severely impaired cognitive skills for daily decisions and total dependence on staff for ADLs, requiring assistance of two or more helpers. Therapy evaluations and care plans showed impaired bed mobility, functional transfers, ambulation, safety awareness, impulsive behavior, attempts to get up unassisted, poor safety awareness, and inability to control body positioning, with bathing documented as requiring total dependence without attempts to initiate. A fall risk assessment scored the resident as high risk for falls. Despite these documented needs, the facility failed to ensure the resident was assisted with at least a two-person assist during mobility and transfers as indicated by the MDS. In addition, after the resident slipped on the floor while being given a shower, the resident was not evaluated and assessed by a licensed nurse as required by the facility’s policies and procedures titled "Falls - Clinical Protocol" and "Falls and Fall Risk, Managing." This failure to follow the resident’s assessed assistance needs and the facility’s fall assessment protocols resulted in the resident’s fall and had the potential to place the resident at risk for recurrent falls.
Failure to Ensure Call Devices Within Reach for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that call devices were within reach for three out of five sampled residents. Observations and interviews revealed that the call light system in the room shared by these residents was not functioning, as evidenced by the lack of illumination at the nurses' station panel. One resident was provided with a table bell as an alternative means to alert staff, while the other two residents had no alternate method to summon assistance. The Registered Nurse Supervisor confirmed that staff would not be aware of residents' needs in a timely manner due to the malfunctioning call light system. Record reviews showed that all three residents had care plans specifying that call lights should be within easy reach and answered promptly, particularly due to their diagnoses and levels of cognitive and physical impairment. The residents involved had conditions such as dementia, Alzheimer's disease, Guillian-Barre syndrome, and severe cognitive impairment, and required varying levels of assistance with activities of daily living. The facility's own policy, revised in October 2024, also required that call lights be within easy reach for residents in bed or confined to a chair.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as required by both facility policy and federal regulations. The resident, who had a history of respiratory tuberculosis, pneumonia, and depression, and was assessed as having severely impaired cognitive skills, was subject to visitation restrictions imposed by a family member. Specifically, two family members were not allowed to visit the resident unless accompanied by another family member, despite there being no evidence of harm or neglect associated with their visits. This restriction was documented in the Interdisciplinary Team notes and enforced by staff, who contacted the restricting family member when the two visitors arrived. The facility's own policies, as well as regulatory guidance, state that visitation cannot be restricted based on the wishes of family members or healthcare power of attorney unless there is an immediate risk to the resident. The ombudsman notified the facility that such restrictions were not permitted, yet the facility did not develop a care plan to address the family conflict or the visitation issue. Interviews with staff confirmed that the facility did not follow its policies or regulatory requirements regarding residents' visitation rights, and no care plan was in place to address the situation.
Failure to Develop Care Plan for Visitation Rights and Family Conflict
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's visitation rights and the conflict between the resident's family members. The resident, who had diagnoses including respiratory tuberculosis, pneumonia, and depression, was assessed as having severely impaired cognitive skills and required moderate assistance with activities of daily living. Despite documentation in the Interdisciplinary Team (IDT) notes that certain family members were not allowed to visit unless accompanied by another family member, there was no corresponding care plan developed to address this issue. Progress notes indicated that the facility was informed by the Ombudsman that visitation could not be restricted unless there was an immediate risk to the resident, and staff interviews confirmed that no harm or neglect had occurred from the restricted family members. Further review revealed that the facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs, but no such plan was created regarding the visitation conflict. Both the Social Services Director and a Registered Nurse acknowledged the lack of a care plan for the resident's visitation rights and family conflict, confirming that the facility did not follow its own policies and regulatory requirements in this instance.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop comprehensive care plans tailored to the individual needs of several residents, as evidenced by multiple observations and interviews. For one resident with severe cognitive impairment and total dependence for activities of daily living (ADLs), staff placed a bedside table and lowered the bed frame in a manner that restricted movement and created a risk of entrapment. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that these actions were inappropriate and not in line with the resident's care plan, which aimed to prevent signs and symptoms of entrapment. Another resident with unspecified dementia and psychosis, who was nonverbal and required supervision for ADLs, was observed wandering the facility and attempting to enter other residents' rooms. Despite the use of a sitter to monitor this resident's behavior, there was no care plan developed to address the risk of elopement or behavioral concerns. Both the LVN and DON acknowledged the absence of a care plan for this resident's behavior. A third resident, also with severe cognitive impairment and total dependence for ADLs, was observed in uncomfortable and unsafe positions in bed, with a tendency to slide off the bed. Staff interviews indicated the need for frequent monitoring and specific positioning due to tube feeding requirements, but there was no care plan developed to address the resident's behavior of sliding off the bed. The facility's policy requires comprehensive, person-centered care plans with measurable goals and timetables, which were not implemented for these residents.
Failure to Timely Provide Hearing Aids and Communication Support
Penalty
Summary
The facility failed to maintain a resident's hearing at the highest attainable level and did not obtain hearing aids in a timely manner for a resident with severe hearing loss. The resident, who had diagnoses including type 2 diabetes and hypertensive heart disease, was documented as having moderately impaired hearing and was eligible for hearing aids under Medi-Cal. Despite an audiology consult and a care plan that included interventions for hearing impairment, the resident's hearing aids were not functioning properly, and the facility did not provide alternative communication tools such as a communication board or pen. The resident reported not having spoken to the social worker about hearing aid issues or follow-up appointments for months and expressed frustration over the inability to watch TV and difficulty communicating with staff. Observations and interviews revealed that staff were unaware of the resident's hearing aid problems and had not implemented care plan interventions to support communication. The social services staff acknowledged the lack of communication tools and the importance of effective communication for resident care. Facility policies required staff to report hearing aid complaints and assist residents in maintaining effective communication, but these procedures were not followed, resulting in the resident experiencing anger, communication barriers, and reduced ability to engage in daily activities.
Failure to Provide and Accurately Document Range of Motion Services
Penalty
Summary
The facility failed to ensure that three residents with limited range of motion (ROM) and mobility impairments received appropriate treatment and services as ordered by their physicians and in accordance with facility policy. Each of the residents had significant medical conditions, including hemiplegia, contractures, encephalopathy, Parkinsonism, epilepsy, muscle weakness, and abnormal posture, and were totally dependent on staff for activities of daily living. Physician orders for these residents included daily or five times weekly passive range of motion (PROM) exercises, application of splints, and use of handrolls, all intended to maintain or improve their ROM and prevent further decline. Record reviews revealed that these residents did not consistently receive the ordered restorative nursing assistant (RNA) treatments during a specified period. Specifically, documentation showed that from 5/15/2025 to 5/19/2025, the residents did not receive the full complement of RNA treatments as prescribed. Additionally, weekly summary notes for RNA treatments were documented in advance, rather than reflecting the actual care provided during the week. This practice was confirmed by interviews with the RNA, who stated that she completed the weekly summaries ahead of time, and by the DON, who acknowledged that documentation should not be completed in advance and must accurately reflect the care delivered. The facility's policies on Resident Mobility and Range of Motion, as well as Charting and Documentation, require that residents with limited ROM receive appropriate interventions and that documentation be objective, complete, and accurate. The failure to provide the ordered treatments and to document care accurately constituted a deficiency, as it did not meet the facility's own standards or professional practice requirements.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
A resident with a history of dysphagia and essential hypertension, who was totally dependent on staff for activities of daily living and had moderately impaired cognitive skills, was observed to have multiple broken, missing, and discolored teeth. The resident reported not having seen a dentist in several months, although she denied being in pain at the time of the interview. Review of the medical record revealed a physician's order allowing for dental consult and treatment as needed, but there were no dental records or progress notes indicating that the resident had received any dental care since admission. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the resident was supposed to receive dental services every 6 to 12 months and as needed, in accordance with facility policy. The lack of documented dental care and absence of dental records for the resident since admission constituted a failure to provide routine and emergency dental services as required by both physician orders and facility policy.
Failure to Follow Dietary Recipe and Measurement Protocols
Penalty
Summary
A deficiency occurred when a dietary staff member failed to follow the facility's recipe for Paprika Beef by not using proper measuring utensils for the Knorr Beef Bouillon. The staff member was observed scooping the bouillon powder with a spoon, without measuring the amount, and adding it directly to the meat. The same spoon was used for stirring the meat and for scooping the bouillon, which could potentially contaminate the bouillon powder. The staff member admitted to not following the recipe and not using measuring cups or spoons as required, and stated she had not received an in-service on following food recipes since being employed at the facility two weeks prior. The Dietary Supervisor confirmed that all dietary cooks are expected to follow recipes and use proper measuring utensils when preparing meals. The supervisor also acknowledged that failure to follow recipes could result in improper seasoning and potential health risks for residents. A review of the facility's job description for cooks and the specific recipe for Paprika Beef further supported the requirement to adhere to established recipes and procedures.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and preparation practices. Leftover tuna was found stored in the refrigerator past its used-by date, and a plate of salad was present without any used-by or expiration date. Several food items, including a large container of dry spaghetti and sour cream, were found with expired dates, and some items had no expiration or used-by dates at all. Additionally, a staff member's personal water bottle was stored in the residents' kitchen refrigerator, and a leaking pipe under the sink was being managed with a green bucket to catch water. The kitchen also contained a container of sour cream that was curdled with clear liquid, and a container of prepared tuna without an expiration date. Dietary staff interviewed were unaware of proper storage times for prepared tuna and did not know the location of the maintenance log. Further inspection revealed that multiple food items were not labeled with expiration or used-by dates, and expired items were not disposed of as required. The kitchen environment was also found to be unsanitary, with debris collecting on the paper towel dispenser, an unclean handwashing/eye washing station sink, and six cutting knives that were not clean. Eight out of seventeen resident trays were noted to be cracked and chipped. The facility's policy requires all refrigerated and frozen foods to be covered, labeled, and dated, and for foods to be monitored and discarded by their used-by dates, but these procedures were not followed.
Failure to Change PPE Between Residents on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established guidelines for the use of Personal Protective Equipment (PPE) when providing care to three residents who were on Enhanced Barrier Precautions (EBP) due to their medical conditions, including hemiplegia, encephalopathy, muscle weakness, and the presence of gastrostomy tubes. All three residents were severely cognitively impaired and totally dependent on staff for activities of daily living. Physician orders and facility policy required the use of gowns and gloves for high-contact care activities, with PPE to be changed and hand hygiene performed between contact with each resident, especially in multi-bed rooms where each bed space is considered a separate room. During an observation, a Certified Nursing Assistant (CNA) was seen wearing the same gown, mask, and gloves while sequentially checking and touching the gastrostomy tube sites of all three residents in the same room, without changing PPE or performing hand hygiene between residents. The Director of Nursing confirmed that staff were required to don and doff PPE appropriately for each resident on EBP and acknowledged that failure to do so could result in the transfer of infection between residents. Facility policy also specified the need to change gowns and gloves and perform hand hygiene when moving from contact with one resident to another in multi-bed rooms.
Failure to Repair Leaking Pipe and Maintain Maintenance Logs
Penalty
Summary
A leaking pipe under the kitchen sink was observed, with a green bucket placed underneath to catch the water. Dietary staff reported that the leak had been present for about one to two weeks and stated that the maintenance supervisor had been notified the previous week. The maintenance supervisor confirmed being notified but indicated the notification occurred more recently. Both dietary and maintenance staff acknowledged that leaking pipes could lead to mold growth and potential illness among residents. Additionally, the facility failed to maintain maintenance repair logs and schedules as required by its own policy. The Director of Nursing stated that the maintenance supervisor is responsible for keeping these records in his office, but there was no evidence provided that these logs and schedules were being maintained. The facility's policy specifies that maintenance services should ensure all equipment and areas are kept in a safe and operable manner, with records maintained accordingly.
Resident Room Size Deficiency and Impeded Mobility Due to Bariatric Bed
Penalty
Summary
The facility failed to ensure that nine resident rooms met the federal requirement of at least 80 square feet per resident in multiple occupancy rooms. Observations and record reviews revealed that several rooms, each measuring 226 square feet and housing three residents, provided only 75.3 square feet per resident, while two other rooms with six beds each provided only 77.6 square feet per resident. Despite a facility letter stating that room sizes would not interfere with care or safety, direct observation showed that the rooms did not meet the minimum space requirements as outlined by federal regulations. Additionally, the placement of a bariatric bed and bedside table in one room further restricted movement for a resident with multiple chronic conditions, including fibromyalgia, muscle weakness, rheumatoid arthritis, hypertension, and spondylosis. This resident, who was cognitively intact and required varying levels of assistance for mobility and personal care, reported feeling confined and unable to move freely within the room, particularly when accessing the bathroom. The arrangement of furniture and insufficient space impeded the resident's ability to move safely and independently, contrary to regulatory standards.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was fully informed and provided consent prior to the administration of psychotropic medications. Record reviews showed that a resident with diagnoses including metabolic encephalopathy, unspecified dementia, and major depressive disorder was prescribed and administered mirtazapine and trazodone. The Minimum Data Set indicated the resident had severely impaired cognitive skills and required maximal to total assistance with activities of daily living. Despite these conditions, the required informed consent documentation for both medications was either incomplete or missing, lacking signatures and confirmation that the resident or responsible party had been informed and had consented to the treatment. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that informed consent forms for the psychotropic medications were not properly completed prior to administration. The facility's own policy requires that informed written consent be obtained and documented in the resident's medical record before initiating psychotherapeutic drug treatment. However, the resident's health record did not contain the necessary signed consents, and both medications were administered without this documentation.
Bariatric Bed Placement Impedes Resident Mobility
Penalty
Summary
The facility failed to ensure that a bariatric bed did not impede the free movement of staff and a resident. During observation and interview, it was noted that a resident's room was crowded due to the presence of a bariatric bed and a bedside table belonging to the roommate. The resident reported feeling closed in and stated that the size of the bariatric bed made it difficult to move around the room. Specifically, the resident indicated that opening the bathroom door caused it to bump into the foot of the roommate's bed, and she could only safely exit her own bed from one side. The resident expressed frustration about not having enough room to move freely in her room. Record review showed that the resident had intact cognition and required varying levels of assistance for mobility and activities of daily living, including walking, toileting, and dressing. The federal guidance reviewed indicated that the measurement of usable living space in the room should include the swing or arc of any door opening directly into the resident's room. The deficient practice resulted in impeding the free movement of the resident and had the potential to impede the free movement of staff and guests.
Failure to Inventory and Safeguard Resident's Personal Belongings
Penalty
Summary
The facility failed to promptly resolve a grievance regarding missing personal belongings for a resident who was severely cognitively impaired and fully dependent on staff for activities of daily living. Upon review, it was found that the facility did not complete an inventory of the resident's personal belongings at the time of admission, as required by facility policy. The resident's family reported missing clothes and personal items to staff but did not receive any follow-up or resolution regarding the missing items. Interviews with facility staff, including the Social Services Director and Director of Nursing, confirmed that an inventory list was not completed upon admission, and that staff are responsible for documenting and updating residents' personal property records. The facility's policy mandates that an inventory be completed at admission and reviewed regularly, but this was not done in this case, resulting in the resident's belongings being unaccounted for.
Unnecessary Physical Restraint Due to Bed and Bedside Table Placement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence for activities of daily living was subjected to unnecessary physical restraint. The resident's bed frame was observed to be set very low with a sagging mattress, which restricted the resident's ability to get out of bed. Additionally, a bedside table was positioned alongside the bed, blocking the resident's movement. These conditions were observed on two separate occasions, and staff interviews confirmed that the setup was intended to prevent the resident from getting up due to a high risk of falls. The facility's own policy states that restraints should only be used for medical symptoms and not for staff convenience or fall prevention, and that equipment should not be used to restrict resident mobility. Both the LVN and DON acknowledged that the bed and bedside table placement restricted the resident's movement and could cause entrapment. The care plan for the resident included a goal to prevent signs and symptoms of entrapment, but the observed practices were inconsistent with this goal and the facility's restraint policy.
Failure to Complete Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to complete required background checks and screenings for two employees with direct access to residents, as mandated by its own policies and procedures. Specifically, the personnel files for a registered nurse and a licensed vocational nurse showed no evidence of background checks or screenings being conducted at the time of hire or thereafter. This was confirmed during interviews with the Director of Staff and Development, who acknowledged that no background checks were performed for these employees, and with the Director of Nursing, who stated that such checks are necessary prior to employment to ensure staff do not have histories that could negatively impact residents. A review of the facility's policy on background screening investigations indicated that background, reference, and criminal conviction checks—including fingerprinting as required by state law—must be initiated within two days of an employment offer and completed before the employee begins work. The failure to follow these procedures placed all 41 residents at risk, particularly given the presence of controlled drug medications in the facility.
Failure to Prevent Accident Hazards and Inadequate Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident with severe cognitive impairment and a known behavior of placing objects in his mouth. Despite documentation in the care plan and staff awareness of this behavior, the resident was observed with access to potentially hazardous items such as a perineal cleanser bottle and multiple disposable razors in his bedside drawer. On separate occasions, the resident was seen putting a cleanser bottle and a blanket in his mouth. Staff interviews confirmed that the resident was not permitted to keep such items within reach, and that frequent monitoring was necessary due to his behavior. Additionally, the facility did not properly evaluate another resident's risk for elopement. This resident, also with severe cognitive impairment and a history of confusion, was observed wandering the facility and attempting to enter other residents' rooms, requiring constant supervision by a sitter or CNA. Despite these behaviors, the resident's elopement risk assessments did not accurately reflect his risk level, and there was no care plan developed to address his risk of elopement. The DON acknowledged that the assessments were inaccurate and that a care plan should have been in place. Facility policies required the review of incidents and accidents for trends and individual vulnerabilities, as well as accurate and complete documentation. However, the observed deficiencies in supervision, environmental safety, and risk assessment for these residents demonstrated a failure to adhere to these policies, placing residents at increased risk for injury and accidents.
Failure to Label Open Dates on Inhalation Medications
Penalty
Summary
Staff failed to label the open date on inhalation medications for two residents with severe cognitive impairment and chronic respiratory conditions. For one resident with type II diabetes mellitus and chronic respiratory failure, the ipratropium-albuterol inhalation solution was being administered every six hours, but the opened foil pouch containing the unit-dose vials was not labeled with the date it was first opened. Similarly, for another resident with chronic obstructive pulmonary disease, congestive heart failure, and muscle weakness, the albuterol inhalation solution was also being administered every six hours, and the opened foil pouch was not labeled with the date of opening. In both cases, the lack of labeling was observed during a medication cart inspection, and the responsible nurse confirmed that the pouches should have been dated according to manufacturer instructions. Manufacturer guidelines for these medications specify that once the foil pouch is opened, the vials must be used within a specific timeframe (one week for ipratropium-albuterol and two weeks for albuterol). The facility's policy also requires checking expiration dates and returning expired medications to the pharmacy. The DON confirmed that the medications should be dated upon opening and that failure to follow these guidelines could affect medication effectiveness. The deficiency was identified through observation, interview, and record review, with direct evidence that the required labeling was not performed.
Improper Medication Storage and Unsanitary Equipment
Penalty
Summary
Facility staff failed to ensure that a resident's diclofenac cream medication was properly stored and secured according to facility policy. The resident, who had diagnoses including metabolic encephalopathy, muscle weakness, and anxiety disorder, was assessed as having severely impaired cognitive skills and was totally dependent on staff for activities of daily living. The resident was not considered safe for self-administration of medication. Despite this, the diclofenac cream was found in the resident's bedside table drawer, accessible to the resident, who was known to put random objects in his mouth. Both a nurse and the Director of Nursing confirmed that the medication should not have been at the bedside due to the resident's confusion and inability to self-administer medications. Additionally, a pill cutter assigned to one of the medication carts was observed to have whitish and orange particles, indicating it was not cleaned and sanitized as required. Nursing staff acknowledged that pill cutters were supposed to be cleaned before and after each use for infection control purposes. Facility policy required medications to be stored in locked compartments and medication preparation areas to be maintained in a clean, safe, and sanitary manner. The failure to properly store medication and maintain clean medication equipment was confirmed through observation, staff interviews, and review of facility policies.
Unpalatable and Overcooked Food Served to Residents
Penalty
Summary
Surveyors observed that the facility failed to provide palatable and nutritious food to residents, as evidenced during a lunch test tray review. The meal, which included pork chop, baked potato, mixed vegetables, dinner roll, cake, milk, and juice, was found to be overcooked and unappetizing. Specifically, the pork chop was hard and lacked flavor, the baked potato was hard near the edges, the mixed vegetables were not palatable, and the dinner roll was hard and overcooked. These findings were confirmed by the Dietary Supervisor, who acknowledged the overcooking of the meal components. Two residents reported that the food was not palatable and specifically mentioned the pork chops being too hard to eat, leading them to request sandwiches as alternatives. One resident, who had broken teeth, was unable to eat the overcooked pork chop. Both residents expressed dissatisfaction with the quality of the food, indicating that it was not meeting their needs. The facility's policy requires that each resident be provided with a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs, but this standard was not met in these instances.
Failure to Prevent Access to Incorrect Meal Tray for Resident at Aspiration Risk
Penalty
Summary
Facility staff failed to ensure that a resident at risk for aspiration, who required 100% feeding assistance, was not left with a breakfast tray within reach. During a facility tour, a breakfast tray intended for another resident was observed on the bedside table next to the resident at risk, with no staff present in the room. The resident's medical record indicated diagnoses including metabolic encephalopathy, dysphagia, obesity, hearing loss, and a gastrostomy, with dietary orders specifying a mechanical soft diet and enteral feeding, along with strict aspiration precautions and the need for full assistance with feeding. Interviews with staff revealed a lack of awareness regarding the placement of the breakfast tray and the associated risks. The CNA interviewed was unaware of the situation and could not articulate the dangers, while the RN and DON acknowledged the potential for serious harm if the resident consumed the incorrect meal. Facility policy required staff to verify correct diet trays before serving, but this protocol was not followed, resulting in the deficiency.
Failure to Provide Prescribed Diet to Resident with Diabetes
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, anemia, vitamin D deficiency, muscle weakness, abnormal gait, and left-sided hemiplegia and hemiparesis, was not provided with a fortified consistent carbohydrate (CCHO) diet as ordered by the physician. The resident's dietary order specified a regular texture, regular liquid consistency, and double portion protein for breakfast and dinner for weight and nutritional management. During a facility tour, the resident's breakfast tray was found on another resident's bedside table, and the resident reported not recalling having breakfast or being aware that the tray was placed there. No staff were present in the room at the time of observation. Interviews with facility staff revealed a lack of awareness regarding whether the resident had received breakfast, and no explanation was provided for why the tray was misplaced. The facility's policies required proper identification and verification of meal trays to ensure residents received the correct diet, as well as timely meal service. However, these procedures were not followed, resulting in the resident not receiving the prescribed meal in accordance with their dietary needs and physician's orders.
Delayed Call Light Response for Residents Needing ADL Assistance
Penalty
Summary
Facility staff failed to answer call lights in a timely manner for two residents who required assistance with activities of daily living (ADLs). One resident, admitted with diagnoses including type 2 diabetes, essential hypertension, and generalized muscle weakness, was assessed as cognitively intact and at high risk for falls. The resident's care plan required that the call light be kept within reach and answered promptly. During observation and interview, the resident reported frequent delays in call light response on every shift, sometimes waiting so long that she fell back asleep, which caused her anger and frustration when needing assistance to use the bathroom. Another resident, with diagnoses including dysphagia, essential hypertension, and generalized muscle weakness, was assessed as moderately cognitively impaired and totally dependent on staff for ADLs. This resident reported waiting more than 30 minutes for staff to respond to call lights, resulting in delays for assistance with changing adult briefs or obtaining water, which also led to anger. Staff interviews confirmed that call lights are expected to be answered promptly, ideally within 3 to 5 minutes, and that delays could result in resident distress or emergencies. Facility policy also required call lights to be answered as soon as possible, but no later than 5 minutes.
Overflowing Waste Equipment Creates Unsanitary and Unsafe Environment
Penalty
Summary
Facility staff failed to maintain a sanitary and comfortable environment by allowing waste equipment in the waste disposal area to overflow, resulting in waste spilling onto the ground. During a facility tour, surveyors observed overflowing trash bins with garbage spilling out, and a maintenance staff member was seen standing on top of the trash bin attempting to press down the garbage. The maintenance staff member acknowledged that trash was not supposed to overflow and that lids should remain shut to prevent exposure, noting that overflowing waste could attract pests and pose a fire hazard. The Director of Nursing confirmed that maintenance staff should not have climbed on the overflowing waste equipment due to the risk of injury and agreed that overflowing trash was an environmental hazard that could cause unpleasant odors and attract pests, potentially exposing residents, staff, visitors, and the public to infectious diseases. Review of facility policies indicated requirements for maintaining a safe, sanitary, and homelike environment, as well as proper maintenance of buildings and grounds, which were not followed in this instance.
Resident Rooms Exceed Maximum Occupancy Requirement
Penalty
Summary
The facility failed to comply with federal regulations requiring that resident rooms accommodate no more than four residents per room. During observations, interviews, and record reviews, it was found that two resident rooms each contained six beds, exceeding the allowable maximum. The facility had submitted a Request for Room Size Waiver, indicating that these rooms had six beds and asserting that the room sizes would not interfere with daily nursing care, safety, or residents' dignity and privacy. The waiver letter also stated that the space would not adversely affect residents' health and safety or impede their well-being. A review of the Client Accommodations Analysis confirmed that the two rooms in question measured 466 and 475 square feet, respectively, with each resident having approximately 77.6 square feet of space. Observations during the survey period noted that residents in these rooms had ample space to move freely, and there was sufficient room for beds, side tables, and care equipment. Despite these observations, the rooms did not meet the federal requirement limiting occupancy to four residents per room.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to follow its own policy and procedures regarding the notification of a physician when a resident refused prescribed tuberculosis (TB) medications. For one resident with severe cognitive impairment and multiple diagnoses including TB, anemia, hypertension, and mobility issues, there were multiple documented refusals of critical medications such as isoniazid, pyridoxine, and rifampin over several dates. Despite these refusals, there was no documentation in the resident's medical record or progress notes indicating that the physician had been notified of the refusals, as required by facility policy. Interviews with staff revealed that the nurse would attempt to re-administer the medications later and only notify the physician after three consecutive days of refusal, which was not in line with the facility's policy. The DON confirmed that although the physician visited frequently and was verbally informed, the refusals were not documented in the progress notes. The facility's policy specifically required that detailed information about treatment refusals be documented in the medical record and that the healthcare practitioner be notified of any refusal of treatment.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to follow its own policy and procedure regarding informed consent for psychotropic medication administration for one resident diagnosed with major depressive disorder, hypertension, and dysphagia. The resident, who had severe cognitive impairment and required significant assistance with activities of daily living, was prescribed mirtazapine for depression. Review of the informed consent documentation revealed that while the resident's responsible party was provided information about the medication, the consent form lacked the physician's signature and did not include the date when staff witnessed the education being provided. Interviews with facility staff, including an LVN, the Social Services Director, and the Director of Nursing, confirmed that the consent was incomplete and not valid according to facility policy, which requires a physician's signature and proper dating of the witness to ensure that education about the risks and benefits of the medication was provided. The facility's policy also specifies that informed consent must be obtained and renewed every six months, and that the physician's signature may be obtained remotely if necessary. The incomplete documentation resulted in the resident potentially receiving a psychotropic medication without being fully informed as required.
Failure to Timely Report and Document Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its policy regarding the timely reporting and investigation of a resident-to-resident altercation, as well as the submission of a conclusion report within the required timeframe. Two residents were involved in altercations on two separate occasions, with staff witnessing and documenting the incidents in progress notes. Despite these documented events, the incidents were not reported to the State Agency as required by facility policy and regulatory standards. Resident 1, who had a history of bipolar disorder, schizophrenia, and peripheral vascular disease, was noted to have mildly impaired cognitive skills but was otherwise independent in activities of daily living and capable of making decisions. Resident 2, with diagnoses including hemiplegia, aphasia, and major depressive disorder, had severely impaired cognitive skills and required moderate assistance with daily activities. Both residents were involved in altercations, with staff noting physical and verbal aggression, and statements were obtained from witnesses. Interviews with facility staff, including the DON and Administrator, revealed that while the incidents were internally investigated and residents were separated, there was no documentation of the investigation or its outcome. Furthermore, the Administrator was not initially made aware of the incidents, and the required reports to the State Agency and other authorities were not submitted in accordance with the facility's abuse reporting policy. This failure resulted in a delay in external oversight and investigation of the alleged abuse.
Failure to Investigate and Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident altercation involving two residents. On two separate occasions, one resident with a history of bipolar disorder and schizophrenia, and another resident with hemiplegia, aphasia, and major depressive disorder, were involved in verbal and physical altercations. Staff witnessed these incidents, including one where a resident became physically aggressive and threatened further altercations, and another where both residents argued about personal space. Despite staff witnessing and documenting the incidents in progress notes, there was no evidence that a formal investigation was conducted or documented as required by the facility's abuse policy. The Director of Nursing (DON) acknowledged the altercations and stated that the residents were separated, but could not provide any documentation of an investigation or its outcome. Additionally, the incidents were not reported to the State Agency as mandated by facility policy. The facility's policies require that all reports of resident abuse, including resident-to-resident altercations, be thoroughly investigated, documented, and reported to appropriate authorities. However, the lack of investigation documentation and failure to report the incidents to the State Agency constituted a failure to follow these procedures, resulting in a deficiency.
Failure to Properly Label and Dispose of Enteral Feeding Bottles
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of enteral feeding bottles for one resident, leading to a deficiency in care. Specifically, the enteral feeding bottle for Resident 3 was observed to be dated but lacked an infusion start time, which is necessary to track the duration of use. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that G-tube feedings should be labeled with both date and time to ensure they are changed within the appropriate timeframe. Further investigation revealed that the enteral feeding bottle had been in use beyond the 48-hour maximum hang time as stipulated by both the manufacturer's guidelines and the facility's policy. The Director of Nursing (DON) confirmed that failing to label the feeding with a date and time could result in prolonged administration, increasing the risk of pathogen growth and potential foodborne illness. Resident 3, who was totally dependent for all functional care and had a severely impaired cognition, was at risk due to this deficiency.
Failure to Administer Correct Oxygen Dosage
Penalty
Summary
The facility failed to ensure that a resident received the correct therapeutic dose of oxygen as ordered by the physician. The resident, who was admitted with diagnoses including encephalopathy, dysphagia, depression, and chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at a rate of 5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during an initial tour and confirmed by a Licensed Vocational Nurse (LVN), who was unable to explain the deviation from the prescribed oxygen flow rate. The Director of Nursing (DON) acknowledged the risk of oxygen overdose, which could lead to lung expansion and potentially cause the resident to stop breathing. The facility's policy on oxygen administration, dated October 2010, specifies that oxygen should be administered at a rate of 2 to 3 liters per minute unless otherwise ordered. The failure to adhere to the physician's order placed the resident at risk of oxygen poisoning and could negatively impact their health and well-being.
Infection Control Breach: Contaminated Medication Administered
Penalty
Summary
The facility failed to adhere to its infection control policy when a licensed nurse administered a medication to a resident after it had fallen onto the floor. This incident involved a resident who was admitted with medical diagnoses including diabetes, hypertension, and generalized muscle weakness. The resident, who had moderately intact cognition and required supervisory to partial/moderate staff assistance with activities of daily living, was given Ativan, a medication used to treat anxiety, after it had been picked up from the floor by the nurse. During an observation and interview, the nurse acknowledged that the facility's process for handling a pill that falls to the ground is to discard it due to contamination risks. The Director of Nursing confirmed this policy, emphasizing that a pill on the floor is considered soiled and should not be administered to residents. Despite this, the nurse handed the contaminated pill to the resident, who then ingested it, potentially exposing the resident to gastrointestinal illnesses.
Verbal Abuse Incident Involving LVN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Licensed Vocational Nurse (LVN). The incident involved a resident with a history of encephalopathy, psychosis, depression, and anxiety disorder, who was admitted to the facility with moderate cognitive impairment. On the day of the incident, the resident was involved in a verbal altercation with the LVN, who admitted to cursing at the resident, violating the facility's abuse prevention policy and code of conduct. The altercation was documented in the resident's situation background assessment and recommendation (SBAR) form, and the resident was placed on 72-hour monitoring. The LVN, who had no previous disciplinary actions and had received initial abuse and code of conduct training, denied verbally abusing the resident but admitted to calling 911 due to the resident's aggressive behavior. The facility's policies clearly state that any form of resident abuse, including verbal abuse, is not condoned. Despite the LVN's denial, the facility's corrective action memo confirmed the LVN's admission of cursing at the resident, leading to the LVN's termination. The facility's failure to prevent this verbal abuse incident resulted in a deficiency report.
Failure to Inform Resident and Representative of Discharge
Penalty
Summary
The facility staff failed to inform a resident and their representative about the discharge from Skilled Nursing Facility 1 (SNF1) to Skilled Nursing Facility 2 (SNF2) before the transfer occurred. This lack of communication led to the resident being transferred to SNF2, where they exhibited aggressive behavior and were difficult to manage. The resident had been admitted to SNF1 with diagnoses including encephalopathy, psychosis, depression, and anxiety disorder, and was noted to have moderate cognitive impairment. Upon arrival at SNF2, the resident became volatile, attempting to elope and exhibiting aggressive behavior towards staff and other residents. Staff at SNF2, including a social services director, licensed vocational nurse, speech therapist, and certified nursing assistant, reported incidents of the resident throwing objects, invading personal space, and being verbally aggressive. Despite attempts to de-escalate the situation and calls for police assistance, the resident's behavior remained unmanageable, leading to their discharge back to SNF1 on the same day.
Failure in Safe Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and handling practices in the kitchen, as observed during a survey. Cook 1 was seen not wearing a hairnet and gloves while preparing food that was to be served directly to residents. This oversight was noted during an initial tour of the kitchen, where Cook 1 admitted to forgetting to wear the necessary protective gear for infection prevention purposes. Interviews with the Dietary Services Supervisor (DSS) and the Director of Nursing (DON) confirmed that all staff were required to wear hairnets and gloves when handling food, as well as wash their hands before entering the kitchen area. The facility's policy and procedures, dated 2018, also indicated that Food & Nutrition employees should avoid bare hand contact with any foods and use suitable utensils or single-use gloves. The failure to adhere to these protocols had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to the 41 medically compromised residents receiving food from the kitchen.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations by accommodating more than four residents in two of its rooms, specifically rooms [ROOM NUMBERS], which each housed six residents. This deficiency was identified through observation, interviews, and record reviews. Despite the residents in these rooms expressing satisfaction with the space and their ability to move freely, the configuration did not meet the regulatory requirements. The residents reported no issues with their rooms, and staff were able to provide care without restrictions. A room waiver request was submitted, highlighting that the rooms were spacious, provided ample closet space, and ensured privacy and safety for the residents.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, ten out of thirteen resident rooms did not meet the 80 square feet per resident requirement for multiple occupancy rooms. Nine of these rooms contained three beds each, with only 75.33 square feet per resident, while two rooms contained six beds each, with one room providing only 70.55 square feet per resident and the other 79.16 square feet per resident. The minimum required square footage for a three-bed room is 240 square feet, and for a six-bed room, it is 480 square feet. Despite the deficiency, observations during the survey indicated that residents had ample space to move freely within their rooms, and there was sufficient space for nursing staff to provide care. Interviews with two residents confirmed that they did not experience any issues with room space or receiving care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not interfere with daily nursing care, safety, or the residents' ability to attain their highest practicable well-being. The Department recommended the continuation of the Room Waiver Request.
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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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