The Earlwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 20820 Earl Street, Torrance, California 90503
- CMS Provider Number
- 055032
- Inspections on file
- 43
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at The Earlwood during CMS and state inspections, most recent first.
A resident with complex medical conditions, including cirrhosis with ascites and esophageal varices, experienced several days of vomiting and 10/10 abdominal pain, repeatedly refusing medications due to fear of vomiting. Nursing staff delayed initiating a change-of-condition evaluation and did not develop a care plan for the vomiting and pain, and assessments of vomitus, abdominal status, and VS were incomplete or undocumented. The NP issued texted orders for Tylenol suppository, non-pharmacologic pain interventions, IV fluids, STAT labs, and immediate transfer to a GACH, but these orders were not consistently implemented, not entered into the EHR, and not documented, and STAT labs were delayed by about 13 hours. Despite ongoing symptoms and reports of reddish vomitus, the resident was not transferred until after vomiting blood and reporting severe esophageal pain, resulting in a prolonged delay between the NP’s initial transfer order and the actual hospital transfer.
A high‑fall‑risk resident with impaired mobility, fluctuating decision‑making capacity, and a history of repeated falls experienced two unwitnessed falls within hours, with the second causing a forehead laceration, skin tears, and bruising. Despite documented high risk and a change in condition after the first fall, staff did not update the fall care plan to include device‑based interventions such as a bed alarm, landing pads, or maintaining the bed in the lowest position, nor did they initiate more frequent rounding or closer supervision as required by facility policy. Nursing staff and the DON acknowledged that the facility’s accident‑investigation policy, which requires identifying causes and implementing pertinent interventions to prevent subsequent falls, was not followed. Separately, surveyors observed that the front door and three of four exit doors lacked active interior alarms, contrary to the facility’s security plan that calls for electronic alarm systems to address resident elopement risk.
Surveyors found that the facility transferred two residents to a GACH for reported declines in ADL status without documenting a clear medical necessity, monitoring, or reassessment. One resident with hemiplegia and ESRD had recently completed PT/OT with documented improvement and no recorded ADL decline or change of condition, yet was sent to the hospital for "decreased participation in ADLs" with a blank COC form and no documented in-house interventions. Another resident with dementia, CHF, and generalized weakness had a COC noting ADL decline and postural imbalance, but concurrent PT/OT notes showed active participation and improvement, and there were no labs, diagnostics, or monitoring documented between the COC and the hospital transfer. Staff interviews and record review confirmed that required documentation of specific unmet needs, facility attempts to meet those needs, and justification for transfer, as outlined in facility policy, was not present for either resident.
A resident with complex medical conditions, quadriplegia, and intact cognition experienced several days of vomiting and generalized pain rated 10/10, but staff did not timely initiate a change of condition process or develop a person-centered care plan with measurable interventions. Nursing notes documented repeated vomiting, a firm abdomen, and NPO status, yet there was no complete assessment of the vomitus, abdominal status, or vital signs for at least one episode, and the resident was not closely monitored as described by an LVN. An RN supervisor confirmed that the change of condition evaluation was delayed by two days, the physician notification lacked documented details, and the resident’s pain and vomiting were never incorporated into an individualized care plan, contrary to facility policy requiring an interdisciplinary, comprehensive care plan based on the resident’s assessment.
A resident with complex medical conditions, including cirrhosis with ascites, esophageal varices, quadriplegia, and chronic spinal disease, repeatedly reported severe abdominal and arm pain rated 10/10 along with several days of vomiting. Despite existing orders for routine pain monitoring, PRN acetaminophen, daily SL suboxone, and non-pharmacologic measures such as warm compresses, repositioning, and relaxation breathing, nursing staff did not complete required pain assessments, did not administer the ordered suboxone, and did not implement or document non-pharmacologic interventions. An RN supervisor failed to initiate a change-of-condition assessment, provide pharmacologic or non-pharmacologic pain relief, or transcribe NP text orders into the record or care plan, and an LVN acknowledged not assessing or documenting the resident’s pain or vital signs. No individualized pain management care plan was developed, and the facility’s pain management and documentation policies requiring systematic assessment, treatment, monitoring, and documentation of pain and changes in condition were not followed, resulting in the resident experiencing unrelieved severe pain and transfer to an acute care hospital.
A resident with multiple complex conditions, including cirrhosis with ascites and quadriplegia, experienced vomiting, pain, and abdominal discomfort, leading an NP to order STAT CBC, CMP, lipase, and lactate tests and to continue IV hydration. Despite the facility’s policy that STAT labs be called in immediately and completed within 4–6 hours, the labs were not drawn until about 13 hours after the order, and the RN Supervisor could not explain the delay, resulting in a failure to complete STAT laboratory testing as ordered.
The facility did not maintain indoor temperatures between 71 and 81°F, resulting in multiple residents with chronic conditions experiencing cold in their rooms and common areas. Despite complaints to staff, no corrective action was taken, and thermostats lacked a minimum temperature setting. The maintenance supervisor confirmed that heat was only activated manually after complaints, and staff were not trained to adjust thermostats, leading to ongoing discomfort for residents.
Two residents who required assistance with personal care were found with call lights out of reach and in soiled incontinence briefs for extended periods. Staff interviews confirmed that call lights should always be accessible and that regular rounding was expected, but delays occurred due to competing duties. Both residents experienced discomfort and feelings of neglect as a result.
A resident with intact cognition and multiple medical conditions underwent two room changes without receiving written notice or providing consent, and the reasons for the moves were not properly documented in the medical record. The resident was not informed of his right to refuse the changes, and facility staff acknowledged that required procedures for notification and documentation were not followed.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care needs.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with end stage renal disease and moderate cognitive impairment returned from a cardiology consultation without progress notes or care instructions being documented in the medical record. Facility staff were unaware of the appointment outcome, leading to a delay in scheduling a planned micro laryngoscopy. Required procedures for documenting and maintaining medical records were not followed.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that a resident with pressure ulcers received appropriate care to promote healing, and failed to implement adequate preventive measures to protect residents at risk for developing new pressure ulcers.
A resident with a history of surgical aftercare, cancer, and GERD, who was at risk for malnutrition, experienced poor food intake and refused to be weighed on several occasions. Staff failed to notify the physician and RD as required, and inaccurately documented the resident's weight despite refusals. This lack of communication delayed the resident's evaluation and care, as confirmed by the RD and DON.
A resident with a history of tongue cancer and swallowing difficulties was not properly monitored for nutritional status, as required weights were not obtained or accurately documented, and declining food and supplement intake was not communicated to the RD or physician. Physician orders for a speech therapy evaluation were not implemented, and requests for a more appropriate diet were not addressed, resulting in a delay in evaluation and care.
The facility did not ensure its QAPI committee monitored whether interventions to address delays in resident care, such as staff in-services on timely call light response, were effective. Multiple grievances from residents about slow responses to call lights were documented, but the QAPI committee did not include this issue as a focus area or evaluate the impact of corrective actions, as confirmed by the ADM and DON.
A resident with dementia and a history of wandering eloped from the facility after being left unsupervised during dinner service. The resident, who wore a wander guard bracelet, was not visually monitored by the CNA, and no alarm was heard when the resident exited. The resident was later found offsite by a member of the public and returned to the facility. Staff interviews confirmed that the wander guard system alone does not prevent elopement and that direct supervision is required.
Two residents with significant medical histories experienced changes in condition, including hypotension and vomiting, but did not have their vital signs reassessed for several hours despite physician recommendations and facility policy. The DON confirmed that vital signs should have been checked every 15-30 minutes after such events.
A resident with COPD was given supplemental oxygen by nursing staff without a current physician's order, despite facility policy and staff acknowledgment that such an order is required. The resident reported using oxygen daily as needed, and staff provided it upon request, with limited documentation of oxygen saturation monitoring.
Nursing staff failed to demonstrate competency in administering oxygen to a resident with COPD, providing supplemental oxygen without a current physician's order and without adequate training on oxygen administration, monitoring, or titration. Facility in-service training did not address these critical areas, and documentation of oxygen saturation was insufficient.
Several residents were housed in rooms with sliding glass doors that could not be locked, and facility entrance doors were left unsecured at night, allowing unrestricted access. Staff and residents expressed concerns about safety, and cockroach infestations were observed in two residents' rooms, causing discomfort and distress. Facility policies required secure and sanitary conditions, but these were not upheld.
Multiple residents with chronic medical conditions were found to be living in rooms with sliding glass doors that could not be locked, and facility entry points were unsecured, allowing unrestricted access. Staff and residents expressed concerns about safety, and cockroach infestations were observed in resident rooms, with no effective follow-up on pest control measures.
Two residents with significant medical and cognitive needs were found with their beds placed against the wall and side rails up, restricting their movement. Staff, including LVNs and the DON, confirmed this setup is considered a physical restraint and requires a physician's order, which was not present. Facility policy states restraints should only be used for medical symptoms after alternatives have failed.
Two residents did not have their care plans updated after falls or to address bed placement against the wall, despite staff and policy indicating these actions were necessary. One resident with cerebral infarction and major depressive disorder required maximal assistance, while another with psychosis and epilepsy was dependent for care. Staff interviews and record reviews confirmed that care plans were not revised as required after incidents or changes in condition.
The facility's QAA and QAPI committee did not effectively monitor or analyze data on an increase in resident falls. The DON reported an uptick in falls and the need for new interventions, but was unable to locate the QAPI binder needed to address the issue after a change in administration. The facility's policy requires ongoing measurement and improvement of care outcomes, which was not followed in this instance.
Multiple live cockroaches were found in the shared room of two residents, both of whom reported feeling uncomfortable and unclean due to the infestation. A CNA confirmed the presence of cockroaches in resident drawers and walls. The Maintenance Director stated that several rooms had been treated for cockroaches but did not follow up to ensure effectiveness, and the DON acknowledged the unsanitary conditions.
Licensed nurses did not notify physicians or document a change of condition when four residents with significant medical histories missed their scheduled morning medications. Staff interviews and record reviews confirmed that required notifications and documentation were not completed, resulting in delayed evaluation and care.
On a day when a licensed nurse called off and another did not show up, the facility did not have enough nursing staff to administer scheduled medications on time. As a result, several residents with complex medical conditions did not receive their morning medications as scheduled, and one resident's cancer medication was repeatedly given late throughout the month. Residents reported distress and concern over the missed or delayed doses, and the DON acknowledged responsibility for staffing coverage.
Several residents did not receive their scheduled medications within one hour of the prescribed time, with some medications being omitted or administered several hours late. Residents with complex medical conditions, including stroke, hypertension, diabetes, and cancer, reported distress and concern over the delays. Staff interviews indicated that staffing shortages contributed to the failure to administer medications as required by facility policy.
Staff failed to perform hand hygiene between resident care and before entering or exiting rooms, with observations showing empty hand sanitizer dispensers in some rooms and none in hallways due to renovations. Both a CNA and an LVN acknowledged not following hand hygiene protocols, citing lack of supplies, while facility leadership confirmed awareness of the issue and the importance of hand hygiene per facility policy.
A resident with cancer and thrombocytopenia did not have required lab tests drawn before a scheduled oncology appointment due to a breakdown in communication and follow-up between the Social Services designee and nursing staff. This resulted in the cancellation of the resident's medical appointment.
The facility did not ensure that the designated IPN had completed the required specialized infection control training, as the IPN's certificate did not show completed hours and the correct certification could not be located. The DON was unaware of the certification issue, and the IPN did not meet the job description's experience and training requirements.
A resident did not receive proper documentation for Meclizine administration, and a care plan was not initiated for a new cough. The resident reported not always receiving medications and having to inform the nurse about the medication type and dosage. The facility's policies on medication administration and nursing documentation were not followed, leading to these deficiencies.
The facility failed to label opened food containers with open and use-by dates, including apple sauce, beef base, and chicken tenders, risking food-borne illnesses. Additionally, pork was improperly defrosted in standing water, contrary to safe defrosting procedures. Staff interviews confirmed these practices violated facility policies.
The facility failed to accommodate the needs of two residents, one with mobility issues due to insufficient room space and another unable to sleep due to a noisy roommate. Despite available beds, no room changes were offered, impacting their health and well-being.
Three residents in an LTC facility were not provided with adequate privacy during care due to insufficient privacy curtains. A resident with hemiplegia and dysphagia, another with severe cognitive impairments, and a third with significant physical and cognitive impairments were all found exposed during care. Staff acknowledged the inadequacy of the curtains, which failed to fully enclose the residents' beds, compromising their privacy and dignity.
The facility failed to update care plans for two residents with ROM and mobility issues. One resident's care plan was not revised after discharge from hospice, delaying interventions for ROM limitations. Another resident's care plan was not updated after discontinuation of PROM exercises and knee splint application. These oversights resulted in inadequate care planning and potential impacts on resident care.
The facility failed to administer medications within the prescribed time frame for two residents, leading to late administration of critical medications. Additionally, there was a failure to accurately document the administration of a controlled substance for another resident, resulting in discrepancies in the medication count. These deficiencies were acknowledged by the LVN and DON, who recognized the increased risk of medication errors and drug misuse.
Two residents were given unnecessary medications, with one receiving antibiotics without meeting criteria and another receiving pain medications against physician orders. This led to potential health risks, including antibiotic resistance and overdose. Facility policies on medication administration were not followed.
The facility failed to properly store and label Insulin Lispro pens and a Retacrit vial, leading to potential medication errors. Insulin pens for two residents were mislabeled, and a Retacrit vial was not discarded after opening, contrary to policy and manufacturer guidelines. The DON acknowledged the risk of medication errors and ineffective treatment due to these practices.
A LTC facility failed to implement proper infection control practices, including hand hygiene during a gastrostomy tube dressing change, observing contact precautions for a resident with MRSA and C. Auris, and ensuring laundry staff used appropriate PPE. Additionally, clean linen was not fully covered during transport, exposing it to potential contamination.
A facility failed to maintain a resident's dignity by having a CNA stand over them while assisting with a meal. The resident, with dementia and dysphagia, required substantial assistance with eating. The CNA acknowledged the need to sit for comfort and safety, as emphasized by the DSD and DON. Facility policy requires dignified care to promote resident well-being.
A facility failed to complete a Change of Condition (COC) form for a resident who developed a UTI, despite being treated with Bactrim. Interviews with staff confirmed that a COC should have been completed to monitor the resident's condition, as required by facility policies.
A facility failed to accurately complete a PASARR for a resident with paranoid schizophrenia and major depressive disorder. The resident's PASARR I screening incorrectly indicated no serious mental disorder and no psychotropic medication use, despite medical records showing otherwise. The DON acknowledged the inaccuracy, which could delay necessary services.
Two residents in the facility did not receive necessary medications for constipation as ordered, leading to a deficiency in care. One resident, with dementia and major depressive disorder, had no bowel movement for five days, yet MiraLAX was not administered as per the care plan. Another resident, also with dementia, did not receive Milk of Magnesia or Dulcolax despite no bowel movement for five days. Staff interviews confirmed the facility's policy to administer laxatives after three days without a bowel movement was not followed.
The facility failed to maintain a medication error rate below 5%, resulting in a 25.93% error rate. Two residents received their medications significantly later than the prescribed times, contrary to the facility's policy. The late administration of medications posed increased health risks, as confirmed by the LVN and DON.
Two residents in an LTC facility experienced significant medication administration errors when their prescribed medications were not given within the required timeframe. A resident with a history of embolism and hypertension received medications nearly two hours late, while another resident with end-stage renal disease and bipolar disorder received medications almost four hours late. The errors were acknowledged by the LVN and DON, who confirmed the facility's policy requires medications to be administered within one hour of the prescribed time.
A resident with severe impairments and medical conditions refused a right elbow splint, but the refusal was inaccurately documented in the RNA records. Observations and interviews confirmed the refusal over two days, yet the records incorrectly showed the splint was applied. The DSD highlighted the need for accurate documentation to communicate with the resident's family or physician.
A resident was inappropriately prescribed antibiotics despite not meeting the LOEB's criteria, as the facility failed to adhere to its antibiotic stewardship program. The IPN did not escalate the issue to the Medical Director, and the DON confirmed the prescription was unnecessary, highlighting a lapse in policy adherence.
Failure to Follow NP Orders and Respond Timely to Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and needed treatment and care to a resident who experienced a significant change of condition, including prolonged vomiting and severe pain. The resident had multiple complex diagnoses, including alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia, and cervical spine disorders, and was dependent for all ADLs. According to progress notes, the resident had been vomiting for three days by 11/21 and reported generalized and abdominal pain rated 10/10, refused medications such as gabapentin and lactulose due to fear of vomiting, and was placed NPO except for sips of water. Despite these symptoms, there was no timely initiation of a change of condition (COC) evaluation or care plan to address the vomiting and pain, and nursing assessments (including description of vomitus, abdominal assessment, and vital signs) were either incomplete or undocumented. The facility did not follow the NP’s texted orders for pain management and transfer to the hospital, and did not document those orders in the medical record. On 11/21, the NP instructed via text to use a Tylenol suppository, warm compresses to the abdomen, and repositioning for the resident’s 10/10 abdominal and arm pain with three days of vomiting; these interventions were not documented as implemented. On 11/22 at 1:35 p.m., the NP texted an order to transfer the resident immediately to a GACH for MRI and further evaluation due to ongoing vomiting, 10/10 abdominal and arm pain, concern for dehydration, and possible esophageal varices. This transfer order was not entered into the EHR, not carried out, and not documented in the resident’s record. Instead, staff reported that the DON advised not to transfer the resident and to start IV fluids and STAT labs, and the NP later texted that if the DON was taking over the case, staff should follow the DON’s direction while completing IV hydration and STAT labs and monitoring the resident. The facility also failed to ensure timely completion of STAT laboratory tests and to follow its own policies on change in condition and transfer. The NP ordered STAT CBC, CMP, lipase, and lactate on 11/22 at 7:13 p.m., but IV fluids were not started until 8:00 p.m., and the STAT labs were not drawn until 8:00 a.m. the next day, approximately 13 hours after the orders were received, despite staff acknowledging that STAT labs should be completed within four hours. The COC evaluation for vomiting was not initiated until 11/22, two days after vomiting began, and there was no COC or care plan initiated for the resident’s 10/10 pain on 11/21. The facility’s transfer/discharge and change-in-condition policies required prompt physician notification and transfer when the resident’s needs could not be met in the facility, but the resident was not transferred until the evening of 11/23, after vomiting blood and reporting severe esophageal pain with red-colored vomitus. This sequence of inactions and delays resulted in a 30-hour delay in transfer from the time the NP first ordered immediate transfer on 11/22 at 1:35 p.m. Additional interviews and record reviews further demonstrated the deficiencies in assessment, monitoring, and documentation. CNAs reported observing multiple vomiting episodes and notifying licensed staff, with the resident complaining of nausea and worsening abdominal pain, while the resident continued to refuse medications due to fear of vomiting. LVN 3 acknowledged that there was no documented assessment of the vomitus (color, smell), abdominal status, or vital signs, and that no COC report or care plan was initiated, stating that lack of documentation meant the assessment was not done and that the resident was not closely monitored. RNS 3 confirmed that vomiting began on 11/20, that the COC was delayed until 11/22, that the NP’s transfer order on 11/22 was not entered into the EHR or carried out, and that the delay in following the NP’s orders placed the resident at risk for harm. The DON acknowledged that there was no COC initiated for vomiting until 11/22, no COC for the 10/10 pain on 11/21, and no care plan for vomiting and pain, despite facility policies requiring prompt response to significant changes in condition and transfer when the resident’s needs could not be met in the facility. The facility’s own policies titled “Change in a Resident’s Condition or Status” and “Transfer or Discharge” required prompt notification of the attending physician and resident/representative when there was a significant change in condition, and transfer when necessary for the resident’s welfare and when needs could not be met in the facility. The documented events show that although the NP was notified and issued orders for NPO status, pain interventions, IV fluids, STAT labs, and immediate transfer, these orders were not consistently implemented, documented, or acted upon in a timely manner. The resident ultimately was transferred to the hospital after vomiting blood and reporting severe pain, where she was treated for hematemesis, minimal esophageal varices, gastritis, and ascites requiring therapeutic paracentesis and blood transfusion. The deficiency centers on the facility’s failure to follow provider orders, to timely assess and respond to a clear change in condition, to complete STAT diagnostics promptly, to create and implement a person-centered care plan with measurable interventions, and to adhere to its own transfer and change-in-condition policies. These failures resulted in a 30-hour delay in transferring the resident to the GACH from the time the NP gave the transfer order on 11/22/2025 at 1:35 p.m.
Failure to Implement Adequate Fall Prevention and Door Alarm Safety Measures
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and provide adequate supervision and fall prevention measures for a high‑risk resident, as well as failure to maintain active door alarms. The resident, identified as having a history of falls, impaired balance, unsteady gait, difficulty walking, and end‑stage renal disease, was dependent or required substantial to maximal assistance for most ADLs, including toileting, transfers, and walking. The resident’s assessments and care plans documented high fall risk, fluctuating capacity to understand and make decisions, and a history of repeated falls. Existing fall care plans focused on a clutter‑free environment, call light use, close monitoring, and toileting schedules, but did not include specific device‑based interventions such as bed alarms, landing pads, or other enhanced safety measures. On one evening, the resident experienced an unwitnessed fall at approximately 9 p.m. after being last seen in the room around 6:30 p.m. CNA and LVN interviews and the change‑of‑condition documentation indicated the resident was found on the floor, with no apparent injuries and unable to explain what happened. Despite this fall and the resident’s known high‑risk status, the care plan titled “Unwitnessed Fall” was not updated to add interventions such as a bed alarm, landing pads, keeping the bed in the lowest position, or increased monitoring. Staff interviews, including from the LVN, RN supervisor, and DON, confirmed that no new fall‑prevention interventions were added after the first fall, and that frequent rounding (e.g., hourly checks) and closer supervision were not implemented. CNA and LVN staff also stated that the resident frequently attempted to get up without assistance and required constant help with toileting, yet monitoring was described as every two hours at best, and not hourly following the change in condition. Approximately four hours after the first fall, around 1 a.m., the resident sustained a second fall, again while attempting to go to the bathroom, resulting in a one‑inch laceration to the left forehead, skin tears to the left elbow, forearm, and hands, and generalized bruising and scabs noted on hospital evaluation. The facility’s policy on Accidents and Incidents‑Investigating and Reporting required prompt investigation, collection and evaluation of information to determine the cause of falls, and identification of pertinent interventions to prevent subsequent falls, including trying various interventions until falling reduced or stopped. Interviews with nursing staff and the DON confirmed that these policy expectations were not met for this resident, as underlying causes were not fully addressed and additional interventions were not implemented between the first and second falls. A separate but related deficiency involved the facility’s failure to ensure that the front door and three of four emergency exit doors had active alarms when accessed from inside the building. Observations with the RN supervisor and a CNA showed that the front door could be pushed open without an alarm and that alarms on three exit doors were not activated, including a door used by staff to transport linens. Staff interviews, including with the RN supervisor, CNA, and the Administrator, confirmed that these doors should have been alarmed from the inside as part of the facility’s security plan to address resident elopement risk and interior building security. The facility’s Security Plan policy referenced the use of electronic alarm systems and resident‑specific security needs, including risk for elopement, but the observed lack of active alarms on these doors did not conform to that plan.
Failure to Assess, Document, and Justify Hospital Transfers for ADL Decline
Penalty
Summary
The deficiency involves the facility’s failure to ensure that transfers and discharges to a general acute care hospital (GACH) were medically necessary, properly assessed, and appropriately documented for two residents. For Resident 33, who had hemiplegia and hemiparesis following a cerebral infarction, contractures, end stage renal disease, muscle wasting, and atrophy, the care plan called for monitoring conditions that might contribute to ADL decline and referring to rehabilitation therapy if a decline was noted. Physician progress notes in October documented no decline in responsiveness or new confusion and instructed staff to call 911 for acute medical symptoms. Nursing notes on 12/8/2025 documented that Resident 33 was alert, oriented, able to make needs known, and refused a doctor-ordered transfer to the hospital for “further evaluation related to decrease in participation in ADLs,” with risks and benefits explained. There was no nursing documentation of an actual ADL decline or change of condition prior to the transfer. Therapy records for Resident 33 showed that from late September through 12/10/2025, the resident received PT and OT and made gains. The OT discharge summary documented that the resident met goals for washing the face with assistance and had a Modified Barthel Index current level of functioning score of 19, exceeding the target of 18, and was discharged from OT on 12/10/2025 with documented gains. PT notes on 12/10/2025 showed improved knee extension and active participation in therapeutic exercises, and the PT discharge summary indicated discharge from PT on that date. The MDS dated 12/18/2025 showed the resident could express wants and understand verbal content, was dependent for several ADLs, used a wheelchair, and had received PT and OT in the last seven days. Interviews with the DOR and DON confirmed that Resident 33 had improved, exceeded therapy goals, and did not have a documented decline; both stated there was no medical necessity or reason for the hospital transfer, and the DOR stated that a decrease in ADLs is not a hospital diagnosis. The COC form dated 12/11/2025 was reported as blank, and LVN 5 stated there was no documentation of a change in ADLs or interventions to prevent hospitalization. Despite the lack of documented ADL decline, Resident 33 was transferred to the GACH on 12/11/2025. The GACH face sheet listed chief complaints of end stage renal disease and elevated lipase, and hospital physician notes documented intermittent abdominal pain, intact sensation, and stable neurological status, with radiology showing nonspecific bowel gas. Facility nursing notes on readmission from the GACH indicated the resident was admitted there for abdominal pain, diagnosed with end stage renal disease and elevated lipase, and received dialysis. Resident 33 reported being transferred for three days with the expectation of receiving therapy, repeatedly asking at the hospital why she was there, and not receiving therapy after returning. Facility staff interviews (CNA 8, LVN 5, RNS 3, DOR, and DON) consistently showed that the stated reason for transfer was decreased participation in ADLs, but there was no supporting documentation of a change of condition, no documented attempts to address ADL issues in-house, and no completed COC form documenting symptoms or interventions. For Resident 44, who had dementia, congestive heart failure, generalized muscle weakness, and bipolar disorder, the MDS indicated intact cognition and a need for partial/moderate assistance with bed mobility and lower body dressing. A COC form dated 8/27/2025 documented a decline in ADL status starting that day, with noticeable regression in physical and postural control and physician notification. The transfer form dated 8/29/2025 stated the resident was transferred to the GACH due to decline in ADL status and noted postural imbalance with right-sided leaning, raising concerns for musculoskeletal weakness or neurological involvement. However, OT treatment encounter notes on 8/26/2025 and 8/27/2025 documented that the resident actively participated and was compliant with skilled interventions, and PT encounter notes on 8/26/2025 and 8/28/2025 indicated improvement and no ADL decline. During record review and interviews, LVN 1, the DOR, the DON, and the MDS nurse confirmed that therapy documentation for Resident 44 showed no decline in mobility or ADLs and that the resident had improved before discharge to the GACH. The MDS nurse and LVN 1 stated there were no laboratory tests or diagnostic tests ordered by the physician in response to the COC on 8/27/2025 and before the transfer on 8/29/2025. They also stated there was no documentation that the resident was monitored or that the resident was not doing well due to ADL decline between the COC date and the transfer date, and no documentation that the resident required transfer to the hospital. The DON stated she could not recall why the resident was discharged to the hospital and acknowledged that not monitoring, reassessing, and documenting the necessity of transfer after a COC had the potential to result in an inappropriate discharge. The facility’s undated policy and procedure titled “Transfer or Discharge” required that when a transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility, the physician must document the specific needs that cannot be met, the facility’s attempts to meet those needs, and the receiving facility’s services available to meet those needs. In the cases of Resident 33 and Resident 44, the survey findings showed that the facility did not document medical necessity for transfer, did not complete or fully document COC forms, did not document monitoring or reassessment after reported changes in ADL status, and did not document attempts to meet the residents’ needs before transferring them to the GACH. These omissions led to the deficiency that residents were transferred without evidence that their needs were assessed or that the facility attempted to meet those needs prior to discharge.
Failure to Develop and Implement Person-Centered Care Plan for Resident With Vomiting and Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan with measurable interventions when a resident experienced ongoing vomiting and severe generalized pain. The resident, who had intact cognitive skills for decision-making, was dependent for all major ADLs and had significant medical conditions including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical spine disorders with myelopathy and spinal stenosis. Despite these complex conditions, when the resident began vomiting and reporting generalized pain rated 10/10, the facility did not timely initiate a change of condition process or create a care plan addressing these acute symptoms. Record review showed that the resident’s vomiting began on 11/20/25 and continued for several days, with documentation on 11/21/25 that the resident had been vomiting for three days, had a firm abdomen, and was placed NPO except for sips of water. Another note the same day documented that the resident had been vomiting throughout the day. However, there was no documented assessment of the vomitus (such as color or smell), no detailed abdominal assessment, and no vital signs recorded in connection with at least one of the vomiting episodes. The LVN on the 3 p.m. to 11 p.m. shift stated the resident vomited twice during his shift, that the first episode contained food, and that he did not observe the second episode, which was assessed by the RN supervisor. He acknowledged there was no documentation of a full assessment and stated that without documentation, the assessment was not done, and that the resident was not closely monitored. Further review and interview with the RN supervisor confirmed that although vomiting started on 11/20/25, the change of condition evaluation was not initiated until 11/22/25. The change of condition form indicated the resident was unable to eat or drink adequately and had nausea and vomiting starting on 11/20/25, with decreased appetite and inability to keep food down, and that the primary care physician was notified, but without documented date, time, or recommendations. The RN supervisor stated that the resident’s pain and vomiting were not care planned and acknowledged that a person-centered care plan with measurable interventions should have been created and implemented when the symptoms began. This failure occurred despite a facility policy requiring the interdisciplinary team to develop an individualized comprehensive care plan based on the resident’s assessment, to guide treatment and care tailored to each resident’s needs.
Failure to Assess, Treat, and Document Severe Pain for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident who repeatedly reported severe pain. The resident had multiple significant diagnoses, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis. Physician orders dated 6/9/25 directed staff to monitor the resident’s pain every shift using a 0–10 scale, administer acetaminophen 325 mg (two tablets) every six hours as needed for mild pain, and document non-pharmacologic interventions such as repositioning, relaxation breathing, and massage. An additional order dated 11/14/25 prescribed daily sublingual suboxone for pain management. The resident’s MDS showed intact cognition and total dependence on staff for mobility and ADLs. On 11/21/25 at 2:59 p.m., nursing progress notes documented that the resident complained of severe pain rated 10/10 and had been vomiting for three days. Text messages between the RN supervisor and the NP that day showed the RN reporting sharp, stabbing abdominal and arm pain rated 10/10 and asking for pain management options. The NP responded with orders to use Tylenol suppository if available, warm compresses to the abdomen, and repositioning to reduce discomfort. Despite this, the pain assessment record showed no pain assessment documented on 11/21/25 after the 10/10 pain complaint, and the MAR for 11/21/25–11/22/25 indicated the resident did not receive suboxone as ordered. The RN supervisor later acknowledged there was no documentation of a pain assessment, no pharmacologic or non-pharmacologic interventions provided on 11/21/25, and that the NP’s text orders for non-pharmacologic interventions were not transcribed into the record or care plan. Additional interviews and record reviews confirmed further lapses. A CNA reported the resident complained of severe abdominal pain on 11/22/25 and that a licensed nurse was notified, but there was no corresponding documentation of assessment or interventions. An LVN stated that on 11/21/25 the resident complained of abdominal pain, but he did not assess the pain’s location, level, or characteristics, did not obtain or record vital signs, did not document the complaint, and did not initiate monitoring despite recognizing this as a change of condition. The resident later reported that she experienced severe abdominal pain with vomiting blood starting on 11/20/25, that she was only given low-dose Tylenol which did not relieve her pain, and that staff refused to give her the sublingual pain medication for several days. The facility’s pain management and charting/documentation policies required systematic identification, assessment, treatment, evaluation of pain, development of an individualized IDT care plan, monitoring of effectiveness, documentation of non-pharmacologic interventions, and documentation of all services and changes in condition. These requirements were not followed for this resident, resulting in unaddressed severe pain and lack of an individualized pain management care plan. The facility also failed to develop and implement an individualized care plan addressing the resident’s pain, despite ongoing pain complaints and existing orders for both pharmacologic and non-pharmacologic interventions. The RN supervisor confirmed that no care plan was created to address the resident’s pain and that the NP’s text orders for warm compresses, relaxation breathing, and repositioning were not incorporated into the care plan or progress notes. Pain assessments documented around the incident showed pain levels of 7/10 on 11/19/25 at 11:15 p.m., 0/10 on 11/21/25 at 4:42 a.m., 0/10 on 11/22/25 at 3:47 a.m., 0/10 on 11/23/25 at 4:15 a.m., and 8/10 on 11/23/25 at 7:35 p.m., but there was a clear gap on 11/21/25 after the documented 10/10 pain complaint. The combination of missing assessments, failure to administer ordered pain medication, failure to provide ordered non-pharmacologic measures, lack of documentation of NP orders, and absence of an individualized pain care plan constituted the deficient practice. The deficient practices resulted in the resident experiencing severe sharp, stabbing arm and abdominal pain rated 10/10 for approximately 48 hours, requiring evaluation and treatment at a general acute care hospital. The resident reported feeling very stressed and frustrated and described the pain as the worst she had ever experienced. The RN supervisor acknowledged that failure to address the resident’s pain could affect the resident mentally and physically and potentially elevate blood pressure. The facility’s own policies on pain management and charting/documentation, which required comprehensive assessment, treatment, monitoring, and documentation of pain and changes in condition, were not followed in this case.
Failure to Complete STAT Laboratory Tests Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of STAT laboratory tests as ordered for one resident. The resident had multiple complex medical conditions, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices without bleeding, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis, and was dependent for most activities of daily living. A physician order dated 11/22/25 at 5:40 p.m. directed STAT laboratory tests, including a CBC, CMP, lipase, and lactate. Text messages reviewed between the NP and the RN Supervisor on the evening of 11/22/25 showed that the NP confirmed the plan to continue IV hydration and complete the STAT labs after being informed that the DON had advised not to transfer the resident to a hospital and instead start IV fluids and STAT labs due to vomiting, pain, and abdominal discomfort. Record review and interview with the RN Supervisor revealed that the STAT labs were not drawn until 8:00 a.m. on 11/23/25, approximately 13 hours after the orders were received, despite the RN Supervisor acknowledging that STAT labs were supposed to be completed within four hours. The lab report confirmed collection at 8:00 a.m., receipt at 10:35 a.m., and reporting at 12:50 p.m. on 11/23/25. The facility’s laboratory services policy stated that when there is a STAT order, staff must immediately call the lab, clearly mark the requisition as STAT, and that the goal is to complete STAT orders within a 4–6 hour timeframe. The delay in obtaining the ordered STAT labs for this resident constituted the cited deficiency.
Failure to Maintain Required Indoor Temperatures for Residents
Penalty
Summary
The facility failed to maintain indoor temperatures within the required range of 71 to 81 degrees Fahrenheit for all sampled residents, as evidenced by observations and interviews. On the day of the survey, temperatures in resident rooms, hallways, and the activity room were recorded between 66 and 69 degrees Fahrenheit. Multiple residents reported feeling cold during both day and night, and several stated that they had notified staff about the low temperatures, but no corrective action was taken. In some cases, residents attempted to mitigate the cold themselves, such as by covering vents with blankets. Residents affected by the deficiency included individuals with chronic medical conditions such as COPD, rheumatoid arthritis, heart failure, hemiplegia, and atrial fibrillation. These residents required varying levels of assistance with activities of daily living and were cognitively able to communicate their discomfort. Despite their complaints, staff did not resolve the temperature issues, and the cold persisted in their rooms and common areas. Facility staff interviews revealed that thermostats were programmed only with a maximum cooling set point and lacked a minimum heating set point. The maintenance supervisor confirmed that heat was turned on manually only when complaints were received, and staff were not trained to adjust thermostats independently. The facility's policy required temperatures to be maintained within the specified range, but this was not consistently implemented, resulting in prolonged periods of cold for residents.
Failure to Ensure Call Light Accessibility and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, both of whom required assistance with activities of daily living. One resident, who was dependent for toileting hygiene and bathing due to diagnoses including dysphagia and heart failure, was observed lying in bed with the call light placed behind the bed, out of reach. The resident's incontinence brief was found to be wet and soiled, and staff acknowledged that it had been that way since the previous shift. The certified nurse assistant (CNA) responsible stated she had intended to change the resident after breakfast but was delayed due to attending to other residents. Another resident, who required supervision or touching assistance for personal care due to diagnoses including type 2 diabetes mellitus and atrial fibrillation, was also found lying in bed with the call light out of reach. This resident's incontinence brief was similarly observed to be wet and soiled. The CNA assigned to this resident stated that she had not yet rounded on the resident because she was distributing breakfast trays and assisting with feeding. The resident reported feeling neglected and uncomfortable due to prolonged periods without staff checking on her or changing her brief. Interviews with staff, including a licensed vocational nurse (LVN) and the director of nursing (DON), confirmed that call lights are expected to be within reach at all times to allow residents to request assistance promptly. Facility policy also requires call lights to be accessible from the bed and other locations. Staff acknowledged that failure to provide timely incontinence care and to ensure call light accessibility could result in residents remaining unattended and in soiled conditions for extended periods, compromising their dignity and delaying care.
Failure to Obtain Consent and Document Room Changes
Penalty
Summary
The facility failed to obtain written consent and provide proper documentation in the medical record prior to making room changes for a resident with intact cognition and multiple medical diagnoses, including type 2 diabetes mellitus, GERD, and muscle weakness. The resident experienced two room changes within the same month, and in both instances, there was no evidence in the clinical record that written notice was given or that the resident consented to the moves. The Room Change Forms indicated the moves occurred, but either lacked a documented reason or did not serve as a substitute for written consent or proper notification. Interviews with the resident revealed that he was not informed of the reasons for the room changes, was not asked for his consent, and was unaware that he could refuse the changes. The social worker acknowledged that it was her responsibility to obtain consent and document the process but admitted to forgetting to do so. The DON confirmed that the facility's process requires informing the resident or responsible party, obtaining consent, and providing notification prior to any room change, none of which were documented for this resident. The facility's policy also requires timely advance notice and documentation of room changes, which was not followed in these cases.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's care or condition.
Failure to Maintain and Document Medical Records Following Outside Consultation
Penalty
Summary
The facility failed to ensure that a resident who attended an outside cardiology consultation returned with progress notes and care instructions that were available in the resident's medical record. The resident, who had end stage renal disease and moderate cognitive impairment, was scheduled for a micro laryngoscopy for vocal cord lesion removal. Physician's orders indicated the need for a cardiology clearance prior to surgery, and the resident had an appointment with a cardiologist. However, upon review, there was no documentation in the medical record of the consultation note or care instructions following the cardiology appointment. Interviews with facility staff revealed that the Social Services Director was initially unaware if the resident attended the appointment and only later obtained the cardiology notes after contacting the cardiologist's office. The Director of Nursing, upon not finding the cardiology note in the medical record, assumed the appointment had not occurred and scheduled another cardiology appointment, resulting in a delay in the planned surgery. Facility policy required that orders and follow-up appointments be documented in the electronic record and that medical records be maintained appropriately, but these procedures were not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing. Additionally, preventive strategies to protect residents at risk for developing pressure ulcers were not adequately carried out, as required by care standards.
Failure to Notify Physician and Dietician of Resident's Poor Intake and Refusal to be Weighed
Penalty
Summary
The facility failed to notify a resident's physician and registered dietician (RD) when the resident exhibited poor food intake and refused to be weighed, as required by facility policy and the resident's care plan. The resident, who had a history of surgical aftercare, malignant neoplasm of the tongue, and gastro-esophageal disease, was identified as being at risk for malnutrition. Documentation showed that the resident was not meeting nutritional needs, consuming only about 53% of meals, and had a poor appetite. The care plan specifically instructed staff to monitor intake, weigh the resident as ordered, and alert the physician and RD to any decline in intake. Despite these instructions, the resident refused to be weighed on multiple occasions, but staff documented the same weight as previous entries, which did not accurately reflect the resident's status. Additionally, the resident's poor meal consumption was not communicated to the RD or physician. The RD confirmed that she was not notified of the resident's refusal to be weighed or the ongoing poor intake, and stated that this lack of communication delayed her ability to reassess and revise the nutritional care plan. The DON also acknowledged that the nursing staff should have notified the RD and physician of these changes, and that the failure to do so resulted in a delay in evaluation and care for the resident. Facility policy required immediate notification of the resident, physician, and representative in the event of significant changes in the resident's condition, including nutritional status. The failure to follow these policies and care plan interventions led to a delay in the resident's evaluation and care, with the potential for the resident to become malnourished and lose weight, as directly stated in the report.
Failure to Monitor and Address Resident's Nutritional Status and Dietary Needs
Penalty
Summary
A deficiency occurred when the facility failed to accurately and consistently assess and monitor the nutritional status of a resident who was at risk for malnutrition. The resident, who had a history of tongue cancer, surgical aftercare, and gastro-esophageal disease, was admitted with difficulty swallowing and a poor appetite. Despite physician orders for regular weight monitoring and a speech therapy (ST) evaluation, the facility did not ensure these orders were carried out. The resident's weights were not properly obtained or documented, with staff entering a weight value even when the resident refused to be weighed, resulting in inaccurate records. Additionally, the resident's declining food and supplement intake was not communicated to the Registered Dietician (RD) or physician as required. The resident's care plan identified her as being at nutritional risk and included interventions such as monitoring intake, offering alternate food choices, and alerting the RD and physician to any decline in intake. However, these interventions were not effectively implemented. The resident and her responsible party repeatedly requested a different diet due to her difficulty chewing and swallowing, but these requests were not addressed, and the resident was not evaluated for an appropriate diet. The RD was not notified of the resident's poor intake or refusal to be weighed, and the ST evaluation was never completed. There was also no evidence of an interdisciplinary team (IDT) meeting to address the resident's nutritional risk, despite facility policy requiring such collaboration. Interviews with facility staff, including the RD, DON, and Director of Rehabilitation, confirmed that there was a lack of communication and follow-through regarding the resident's nutritional needs. The resident reported feeling weak and unhealthy due to inadequate nutrition and an inappropriate diet. Facility policies required weekly weights after admission, comprehensive care planning, and IDT involvement when care was refused or requested, but these were not followed. The failure to monitor, document, and communicate the resident's nutritional status and to implement physician orders led to a delay in evaluation and care, placing the resident at risk for malnutrition and weight loss.
Failure to Monitor Effectiveness of Interventions for Timely Resident Care
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee monitored interventions related to delays in resident care, specifically regarding timely response to call lights. Multiple grievance reports documented concerns from residents about delays in receiving assistance after activating call lights. These grievances were noted on several occasions, with residents expressing dissatisfaction with the timeliness of care and customer service. Despite these documented concerns, the facility's QAPI committee did not include call light response or customer service as areas of focus in their most recent program reviews. While the Director of Nursing (DON) provided in-service education to staff on the importance of timely call light response, there was no system in place to evaluate whether these interventions were effective in improving response times or overall resident care. Interviews with the Administrator and DON confirmed the absence of a monitoring or evaluation process for these corrective actions. The facility's policy and procedure for the QAPI program outlined responsibilities such as collecting and analyzing performance data, identifying and monitoring facility systems, and evaluating performance improvement projects. However, the actual practice did not align with these responsibilities, as the QAPI committee did not track or assess the effectiveness of interventions implemented to address the identified delays in resident care.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a documented history of elopement and wandering behaviors was able to leave the facility unsupervised and without staff knowledge. The resident, who had diagnoses including Parkinson's disease, dementia, and muscle weakness, was assessed as being at risk for elopement. The care plan for this resident included interventions such as engaging in purposeful activity, identifying triggers and patterns for wandering, and ensuring close monitoring in common areas or during activities. Additionally, a wander guard bracelet was ordered and was to be checked for placement every shift. On the day of the incident, the resident was served dinner in the hallway and was left unsupervised while the CNA distributed dinner trays to other residents. The CNA did not maintain visual confirmation of the resident's location and did not inform other staff that she would be unable to monitor the resident directly. At some point, the resident left the facility through an unknown door, and the wander guard alarm did not alert staff to the resident's exit. The absence of an alarm and lack of direct supervision allowed the resident to leave the premises undetected. The resident was found offsite by a member of the public, who contacted emergency services and the facility. The resident was subsequently returned to the facility. Interviews with staff, including the DON and ADM, confirmed that the wander guard system is a monitoring tool and does not prevent elopement, emphasizing that staff supervision and monitoring are essential. The facility's own policies and product documentation also indicated that close personal surveillance is necessary in addition to monitoring equipment.
Failure to Monitor Residents After Change in Condition
Penalty
Summary
The facility failed to monitor and reassess two residents after a change in their medical condition. For one resident with a history of left femur fracture and hypertension, the resident experienced vomiting, sweating, hypotension, and tachycardia. The physician was notified and recommended continued monitoring, and 911 was called, but the resident initially refused transfer. The resident had another episode of vomiting several hours later and was then transferred to a hospital. During the six-hour period between the initial episode and the transfer, there was no reassessment of vital signs documented. For another resident with diagnoses of congestive heart failure and end stage renal disease on dialysis, the resident was found to have low blood pressure. The physician was notified and recommended blood pressure checks every thirty minutes for three times. However, there was no documentation of vital sign reassessment for approximately six hours until 911 was called and the resident was transferred. The Director of Nursing confirmed that vital signs should have been reassessed every 15-30 minutes after a change in condition, even without a physician order.
Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a diagnosis of chronic obstructive pulmonary disease (COPD) was administered supplemental oxygen without a current physician's order. The resident's admission and assessment records indicated a need for supervision and assistance with daily activities, but there was no active order for oxygen administration after the previous order was discontinued. Despite this, the resident reported using 2 liters per minute of oxygen daily as needed, and nursing staff provided oxygen upon the resident's request. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that a physician's order is required for oxygen administration, specifying the amount and monitoring parameters. The facility's policy also mandates verification of a physician's order before administering oxygen. However, documentation and staff statements revealed that oxygen was given to the resident without such an order, and oxygen saturation was only documented twice after the order was discontinued.
Failure to Ensure Nursing Staff Competency in Oxygen Administration
Penalty
Summary
Licensed nursing staff failed to demonstrate competency in administering oxygen to a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted and readmitted with a diagnosis of COPD and required supplemental oxygen. However, after the physician's order for oxygen was discontinued, nursing staff continued to provide oxygen to the resident upon request, without a current physician's order specifying the amount or monitoring requirements. Documentation showed that oxygen saturations were only recorded twice after the order was discontinued. The nurse involved could not recall receiving training on oxygen administration, oxygen orders, or monitoring. Interviews with facility leadership revealed that the in-service training provided to nursing staff did not cover essential topics such as validating physician orders for oxygen, monitoring requirements, or titration of oxygen. The Director of Nursing acknowledged that staff should be trained and in-serviced on these aspects to ensure proper use of oxygen. The facility's policy on in-service training stated that staff should demonstrate competency in training topics, but this was not reflected in the training provided regarding oxygen administration.
Failure to Maintain Secure, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Three residents were housed in rooms with sliding glass doors that were broken, off track, and unable to be locked from the inside, allowing open access from outside the facility. The gates and fences surrounding the facility were also broken or missing locks, and the front and back entrance doors were found unlocked or ajar during nighttime hours, with no staff present or alarm systems in place. Staff and residents expressed concerns about safety, with several stating that anyone could enter the facility or their rooms without restriction. Additionally, the rooms of two residents were found to be infested with cockroaches. During an inspection, cockroaches were observed running from behind furniture and inside air fresheners. Both residents reported feeling dirty and uncomfortable due to the infestation, and staff confirmed the presence of cockroaches in resident rooms and drawers. The Maintenance Director acknowledged that pest control treatment had been performed in several rooms previously but admitted there was no follow-up to determine its effectiveness. The facility's own policies and job descriptions require maintaining a safe, secure, and sanitary environment, including ongoing pest control and ensuring that all doors and grounds are secure. Despite these requirements, the facility did not maintain functional locks on resident room doors, failed to secure the facility entrances, and did not effectively address pest infestations, directly impacting the residents' dignity, mood, and right to a homelike and safe environment.
Failure to Ensure Safe, Secure, and Clean Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Resident rooms with sliding glass doors facing the outside were found to be open, unable to close, or unable to lock, leaving the rooms unsecured. The gates and fences surrounding the facility were broken or missing locks, and the front and back doors to the facility were observed to be unlocked or ajar, with no staff present or alarm system in place. Staff and residents expressed concerns about safety due to these unsecured entry points, and the Maintenance Director confirmed awareness of the broken doors and lack of locks. Residents affected by these deficiencies included individuals with intact cognition and various medical conditions such as diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, osteoarthritis, anxiety, and congestive heart failure. These residents required varying levels of assistance with activities of daily living. Both residents and their caregivers voiced concerns about the inability to secure their rooms, with personal belongings left vulnerable and a general sense of insecurity due to the facility's lack of physical security measures. Additionally, the facility failed to maintain a clean and pest-free environment in resident rooms. Multiple cockroaches were observed in the rooms of two residents, including inside personal items such as air fresheners and nightstand tables. Staff confirmed the presence of cockroaches and noted that previous pest control treatments had not been followed up to ensure effectiveness. Facility policies required ongoing pest control and maintenance of a clean, sanitary environment, but these were not upheld, as evidenced by the continued presence of pests and lack of follow-up.
Use of Bed Placement as Physical Restraint Without Proper Authorization
Penalty
Summary
Two residents were found to have their beds positioned against the wall, with the opposite side rails raised, effectively restricting their freedom of movement. Both residents had significant medical histories, including cerebral infarction, major depressive disorder, psychosis, and epilepsy. Assessments indicated that one resident had moderately intact cognition and required maximal assistance with transfers, while the other had intact cognition but was dependent on staff for dressing, toileting, and bathing. Observations confirmed that the beds were placed against the wall, and this setup was verified by staff during interviews. Staff, including two LVNs and the Director of Nursing, acknowledged that placing a bed against the wall is considered a form of physical restraint, which restricts resident movement and could potentially cause injury. Facility policy requires that restraints only be used for medical symptoms and after other alternatives have been tried unsuccessfully, with a physician's order. In these cases, there was no indication that such orders or alternative measures were in place, leading to the deficiency.
Failure to Revise and Individualize Care Plans After Falls and Bed Placement
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives, timeframes, and interventions for two residents. Specifically, the care plan for one resident was not reviewed or revised after each incident of falling, despite the resident experiencing multiple falls. Additionally, care plans for both residents did not address the placement of their beds against the wall, which staff identified as a necessary communication tool and a form of restraint that should be care-planned. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated after falls and when beds are positioned against the wall, but this was not done. Resident records indicated that one resident had a history of cerebral infarction and major depressive disorder, requiring maximal assistance with transfers, while the other had diagnoses of psychosis and epilepsy and was dependent on staff for dressing, toileting, and bathing. Facility policy required ongoing assessment and revision of care plans when residents' conditions changed, and specifically called for care plans to address the use of restraints. The failure to update and individualize care plans as required was confirmed through record review and staff interviews.
Failure to Monitor and Address Increase in Resident Falls
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to monitor, review, and analyze data related to performance improvement issues, specifically regarding an increase in resident falls. During an interview, the DON acknowledged that there had been an increase in falls and that new interventions for fall prevention were needed, but also stated that the QAPI binder, which would address the increase in falls, could not be located following a change in administration. A review of the facility's QAPI policy indicated that the program is intended to measure care outcomes and implement performance improvement projects, but these processes were not effectively carried out in relation to the issue of falls. This lack of monitoring and analysis by the QAA and QAPI committee resulted in a failure to identify and address systemic issues related to resident falls, as required by facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain a consistent and effective pest control program, as evidenced by the presence of multiple live cockroaches in the shared room of two residents. During an observation, one resident moved his nightstand and air freshener, revealing multiple cockroaches both running and inside the air freshener. Both residents expressed discomfort and dissatisfaction with the ongoing cockroach issue, stating it made them feel dirty and creepy. A CNA confirmed seeing cockroaches in resident drawers and coming out of the walls, validating the residents' complaints. The Maintenance Director acknowledged that 23 rooms had been treated for cockroaches previously but admitted there was no follow-up to determine if the treatment was effective. The Director of Nursing also recognized that the presence of cockroaches was unsanitary and could make residents feel gross. The facility's pest control policy requires an ongoing program to keep the building free of insects and rodents, and the maintenance director's job description includes ensuring the facility is maintained to protect the health and safety of residents. Despite these policies, the observed infestation and lack of follow-up contributed to the deficiency.
Failure to Notify Physician and Document Change of Condition After Missed Medications
Penalty
Summary
The facility failed to notify physicians when four residents did not receive their scheduled 9:00 a.m. medications on a specific date. Licensed nurses did not document a change of condition (COC) or inform the residents' physicians about the missed doses, as required by facility policy. This lack of notification and documentation was confirmed through interviews with nursing staff, who acknowledged that such actions should have been taken to ensure proper monitoring and care. The residents involved had significant medical histories, including conditions such as cerebral infarction, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. Each resident's medication administration record indicated that the scheduled morning medications were not administered, and there was no evidence of physician notification or COC documentation in the records. Interviews with staff, including LVNs, the facility pharmacist, and the Director of Nursing, confirmed that the standard procedure when medications are missed is to notify the physician and document the event as a COC. The facility's job descriptions and policies also require reporting of medication errors and changes in condition to the appropriate parties. However, these procedures were not followed in this instance, resulting in a delay of evaluation, care, treatment, and monitoring for the affected residents.
Failure to Provide Sufficient Nursing Staff Resulting in Missed and Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on a specific day when one licensed nurse called off and another was a no call no show, resulting in the inability to administer scheduled medications to multiple residents at the designated times. This staffing shortage directly led to four residents not receiving their scheduled 9:00 a.m. medications, as documented in their Medication Administration Records (MARs). Additionally, one resident's medication for breast cancer was administered late on multiple occasions throughout the month, as shown in the Administration Details Report. Resident records reviewed indicated that the affected individuals had significant medical histories, including conditions such as stroke, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. These residents required moderate assistance with activities of daily living and had intact cognition. Interviews with the residents confirmed that medications were not administered on time, with some reporting delays of several hours and expressing concern and distress over the missed or late doses. The Director of Nursing (DON) acknowledged responsibility for managing the licensed nurse schedules and stated that she should have covered the shift when the staffing shortage occurred. Facility policy and the DON's job description both require ensuring sufficient and competent staffing to meet resident needs, but these requirements were not met on the day in question, resulting in the observed deficiency.
Failure to Administer Medications Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications for four out of five sampled residents were administered within one hour of their scheduled administration times, as required by the facility's policy and procedures. Specifically, multiple residents did not receive their prescribed morning medications on time, with some medications being omitted entirely on certain days. Medication Administration Records (MARs) and Administration Details Reports showed that scheduled medications, including critical drugs for conditions such as atrial fibrillation, hypertension, diabetes, and cancer, were either not given or administered several hours late. Residents affected by these delays had significant medical histories, including diagnoses such as stroke, atrial fibrillation, hypertension, diabetes mellitus, peripheral vascular disease, cancer, and chronic obstructive pulmonary disease. Interviews with residents confirmed that medications were often given late, sometimes not until several hours after the scheduled time, and in some cases, not at all. Residents expressed concern, frustration, and distress over the missed or delayed medications, emphasizing the importance of timely administration for their health conditions. Staff interviews revealed that the delays and omissions were partly due to staffing shortages, with the Director of Nursing acknowledging responsibility for ensuring coverage when licensed staff were absent. Licensed nurses and the facility pharmacist confirmed the risks associated with missed or delayed administration of medications, particularly those for blood pressure, blood thinning, and seizure control. The facility's policy clearly stated that medications must be administered within one hour of the prescribed time, and the Director of Nursing's job description included monitoring medication passes to ensure compliance.
Failure to Maintain Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain proper infection control practices when a CNA and an LVN did not perform hand hygiene between resident care and before entering or exiting resident rooms. Observations revealed that two out of four resident rooms lacked hand sanitizing gel in the dispensers, and there were no hand sanitizing gel dispensers in the hallways due to ongoing renovations. Both the CNA and LVN admitted to not performing hand hygiene, citing empty dispensers as the reason, but acknowledged the importance of hand hygiene in preventing the spread of infection. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that staff were educated on the importance of hand hygiene and the facility's policy required hand hygiene before and after resident care, as well as before entering and after exiting resident rooms. The Infection Prevention Nurse was aware of the lack of hand sanitizing gel in some rooms due to a back order and stated that staff were instructed to wash their hands at the nurses' station. The facility's policy emphasized that hand hygiene products and supplies should be readily accessible to encourage compliance.
Failure to Obtain Ordered Laboratory Tests Resulting in Missed Medical Appointment
Penalty
Summary
The facility failed to obtain laboratory tests as ordered by a medical doctor prior to a resident's scheduled appointment. A resident with a history of malignant neoplasm of the right breast, bone involvement, and thrombocytopenia was admitted to the facility and required laboratory tests before an upcoming oncologist appointment. The resident's Minimum Data Set indicated intact cognition and a need for moderate assistance with toileting and dressing. The Social Services designee reported that she was responsible for notifying the RN to arrange laboratory draws for residents. She informed the RN that the resident required laboratory tests for the upcoming appointment, but the RN left early that day, and the SSD did not follow up to ensure the tests were completed. As a result, the laboratory tests were not drawn, leading to the cancellation of the resident's oncologist appointment.
Infection Preventionist Lacked Required Training and Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Prevention Nurse (IPN) had completed the required specialized training in Infection Control and Prevention. Record review showed that the IPN's certification, dated 12/30/2024, was from CDC Train but did not indicate the hours completed. During interviews, the IPN stated she began working at the facility as a new graduate licensed nurse in November 2024 and had been serving as the IPN since February 2025. She was unable to locate the correct Infection Preventionist certificate and believed the CDC Train certificate was sufficient. The Director of Nursing (DON) was unaware that the IPN had the incorrect certification and acknowledged the importance of having a full-time IP nurse with the correct credentials. The facility's job description for the Infection Preventionist required at least two years of clinical experience and appropriate training, which was not met in this case.
Failure to Document Medication and Initiate Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care as per physician orders and the resident's preferences and goals. Specifically, the facility did not document the administration of Meclizine, a medication for dizziness, on the Medication Administration Record (MAR) for two instances. This lack of documentation was confirmed by interviews with the Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), who acknowledged that if a medication is not signed on the MAR, it is considered a medication error. The resident reported not always receiving medications and having to inform the nurse about the medication type and dosage needed. Additionally, the facility did not initiate a plan of care or document a change of condition when the resident developed a new onset of cough. The resident reported coughing since the week of admission, and although cough medicine was administered, there was no documentation of the cough or monitoring for it. The LVNs confirmed that the cough was not recorded on the MAR, and a care plan was not initiated, which is necessary for following interventions to care for the resident. The facility's policies on administering medications and nursing documentation emphasize the importance of proper documentation and monitoring, which were not adhered to in this case.
Food Safety and Defrosting Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of opened food containers, which included an open container of apple sauce, beef base, and frozen chicken tenders stored in a Ziploc bag. During interviews, the Dietary Aide and Dietary Manager confirmed that all opened food containers must have an open date and a use-by date to prevent the use of expired food, which could lead to food-borne illnesses. The Director of Nurses also emphasized the importance of labeling to ensure food freshness and prevent bacterial growth. Additionally, the facility did not follow safe defrosting procedures for pork, as it was left in a bowl of standing water in the sink. The Cook and Dietary Manager acknowledged that cold water must be running on the meat during defrosting to prevent it from reaching the temperature danger zone where bacteria can grow. The Director of Nurses reiterated the necessity of proper defrosting methods to avoid bacterial contamination. The facility's policies and procedures require safe food handling and proper labeling, which were not adhered to in these instances.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the individual needs and preferences of two residents, leading to deficiencies in their care. Resident 37, who has conditions such as diabetes mellitus, hyperlipidemia, and hydronephrosis, expressed concerns about the insufficient space in his room. The limited space hindered his mobility, access to his closet, and the ability to move his wheelchair comfortably, especially when staff provided care to his roommate. Despite his complaints, no room change was offered, and the Maintenance Supervisor confirmed the room's inadequate size. Resident 179, diagnosed with heart failure, weakness, angina pectoris, and acute kidney failure, reported being unable to sleep due to the noise from his roommate. Despite informing staff members and the issue being discussed in an Interdisciplinary Team Meeting, the concern was not addressed, and no room change was provided. The facility had available beds, but the Social Service Director cited room availability as a reason for not transferring the resident. The facility's policies on accommodating individual needs and providing a homelike environment were not adhered to, as evidenced by the failure to address the residents' concerns. The Director of Nursing acknowledged that insufficient living space and noise could negatively impact the residents' health and psychosocial well-being. The facility's census showed available beds, contradicting the reason given for not accommodating the residents' requests for room changes.
Inadequate Privacy Curtains Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure complete privacy for three residents during care, as observed by surveyors. Resident 34, who was admitted with conditions such as hemiplegia and dysphagia, was found without a privacy curtain on the right side of the bed, leaving them exposed during care. Despite the door being closed, the lack of a full privacy curtain meant that Resident 34 was not fully shielded from view, which was confirmed by CNA 3 who noted the inadequacy of the curtain. Similarly, Resident 6, who had severe cognitive impairments and was dependent on staff for care, was also found without adequate privacy. The privacy curtain only covered one side of the bed, leaving Resident 6 exposed to the roommate and anyone entering the room. CNA 4 acknowledged the issue, stating that the curtain did not provide full coverage, which was necessary for maintaining the resident's dignity during personal care activities. Resident 17, who had significant physical and cognitive impairments, was also affected by the lack of complete privacy. The curtain in Resident 17's room did not fully enclose the bed, leaving the resident exposed during care. RNA 2 confirmed the privacy issue and closed the door to provide some level of privacy. The facility's policy on dignity and privacy was not adhered to, as the staff failed to ensure that the residents were fully covered during care, compromising their privacy and dignity.
Failure to Revise Care Plans for Residents with ROM and Mobility Concerns
Penalty
Summary
The facility failed to revise the care plans for two residents with limitations in range of motion (ROM) and mobility concerns. For Resident 6, the care plan was not updated after the resident was discharged from hospice care on January 13, 2024. The resident had significant ROM limitations in both arms and legs, and the care plan review was delayed, starting on February 13, 2024, and completing on March 12, 2024. During this period, the resident did not receive any interventions to address ROM limitations, as the Interdisciplinary Team (IDT) conference with the resident's representative was not conducted timely. Resident 6 was admitted with multiple diagnoses, including epilepsy, dementia, dysphagia, and contractures in various joints. The Minimum Data Set (MDS) assessment indicated a significant change in status, but the care plan was not updated within the required timeframe. The Director of Rehabilitation confirmed that physical and occupational therapy were not notified of the resident's change in condition until March 5, 2024, resulting in a lack of intervention for ROM impairments until that date. For Resident 20, the care plan was not revised after the discontinuation of passive range of motion (PROM) exercises for the left leg and the application of the left knee splint on September 13, 2024. The resident had a history of hemiplegia and contracture of the left lower leg. Despite the physician orders being discontinued, the care plan continued to include interventions for the left leg, which should have been updated to reflect the current orders. The MDS Coordinator acknowledged that the care plan should have been revised when the physician orders were discontinued.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer medications within one hour of their prescribed time, as per the facility's policy and procedure titled 'Administering Medications,' dated April 2019. This deficiency affected two residents during medication administration. Resident 1, who was admitted with diagnoses including acute embolism, thrombosis, hypertensive heart disease, anemia, and paranoid schizophrenia, received medications one hour and 46 minutes after the scheduled administration time. Similarly, Resident 228, diagnosed with end-stage renal disease, bipolar disorder, and recurrent major depressive disorder, received medications three to four hours after the scheduled administration time. Licensed Vocational Nurse (LVN) 1, who was not familiar with the residents on this side of the facility, acknowledged the late administration and the associated risks. The facility also failed to accurately account for the administration of a combination medication, hydrocodone-acetaminophen, on the Controlled Drug Record (CDR) for Resident 332. The medication card for hydrocodone-acetaminophen showed a discrepancy in the number of tablets remaining compared to the CDR, indicating a failure to document the administration of the medication immediately after it was given. LVN 4 admitted that the CDR should have been documented and signed immediately after administering the medication to ensure accurate record-keeping and prevent potential medication errors, drug misuse, and diversion. Interviews with the Director of Nursing (DON) confirmed that medications should be administered within one hour of their prescribed time and that controlled substances must be documented immediately after administration. The DON acknowledged that the late administration of medications and the failure to document controlled substances increased the risk of medication errors, drug misuse, and diversion. The facility's policies and procedures on administering medications, medication errors, and controlled substances were reviewed, highlighting the importance of timely administration and accurate documentation.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, leading to potential health risks. Resident 25 was prescribed antibiotics, specifically Ciprofloxacin and Keflex, without meeting the LOEB's criteria for significant infection, which are guidelines used to determine the necessity of antibiotics. Despite the Infection Prevention Nurse's awareness that the criteria were not met, the primary physician insisted on continuing the prescription, and the Medical Director was not consulted. The Director of Nursing acknowledged that the prescription was inappropriate and highlighted the risk of antibiotic resistance due to unnecessary use. Resident 29 was administered pain medications, Tramadol and Morphine Sulfate, inappropriately according to physician orders. The resident's Medication Administration Record showed that Tramadol was given for mild pain levels, and Morphine was administered even when the pain level was zero or mild, contrary to the prescribed guidelines. The Assistant Director of Nurses and the Director of Nursing both confirmed that the medications were given incorrectly, putting the resident at risk for overdose and adverse side effects. The facility's policies on medication utilization and administration were not followed in these cases. The policy requires that medications be prescribed and administered based on specific criteria and physician orders, considering the resident's condition and needs. The failure to adhere to these protocols resulted in the administration of unnecessary and potentially harmful medications to the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that Insulin Lispro prefilled pens were stored and labeled according to the manufacturer's specifications and the facility's policy. During an inspection of Medication Cart 3, it was observed that the insulin pens for two residents were labeled with different opened dates, which could lead to confusion. One resident's insulin pens were stored in a bag labeled with a different medication name, further increasing the risk of medication errors. The Director of Nursing acknowledged that this practice could lead to medication errors and abnormal blood glucose levels. Additionally, the facility did not properly handle a single dose vial of Retacrit for another resident. The vial was found opened without an open date or expiration date documented, contrary to the manufacturer's requirements. The Licensed Vocational Nurse admitted that the vial should have been discarded after opening, and the Director of Nursing confirmed that improper storage could lead to ineffective treatment of anemia. The facility's policy on medication labeling and storage was not followed, as medications were not stored in their original packaging, and labels did not consistently match the contents. The pharmacist confirmed that medications requiring refrigeration should not be stored together in a bag with a different medication's label. The policy also required that multi-dose vials be dated and discarded within 28 days, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observed deficiencies. In one instance, a treatment nurse did not perform hand hygiene after removing a dirty dressing and before applying a clean dressing to a gastrostomy tube site for a resident. This resident, who was admitted with multiple diagnoses including epilepsy and dementia, was dependent on staff for daily activities and had a care plan in place to monitor for signs of infection. The nurse acknowledged the lapse in hand hygiene, which was confirmed by the Director of Nursing, who emphasized the risk of cross-contamination and infection. Another deficiency was observed when staff failed to observe contact precautions for a resident with MRSA and C. Auris infections. The Maintenance Supervisor and a visiting resource president entered the resident's room without wearing PPE, despite the resident being on contact precautions. The Director of Nursing and Infection Preventionist Nurse confirmed the need for PPE and hand hygiene to prevent the spread of infection, as outlined in the facility's policy. Additionally, the facility's laundry staff did not adhere to infection control protocols. A laundry assistant was observed handling soiled linen without proper PPE, such as eye protection and PVC dipped gloves, and failed to perform hand hygiene at appropriate times. Furthermore, clean linen was transported in a wired basket that was not fully covered, exposing it to potential contamination. These actions were contrary to the facility's policies, which require full coverage of clean linen during transport and the use of appropriate PPE when handling soiled linen.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain respect and dignity for a resident by having a Certified Nursing Assistant (CNA) stand over the resident while assisting them during a meal. The resident, who was admitted with diagnoses including unspecified dementia, cerebral infarction without residual effects, and oropharyngeal dysphagia, required substantial assistance with eating. During an observation, the CNA was seen standing over the resident while feeding them lunch, which was not in accordance with the facility's policy for providing a dignified dining experience. Interviews with the CNA, Director of Staff Development (DSD), and Director of Nursing (DON) revealed that the CNA acknowledged the need to sit down while feeding the resident to ensure comfort and safety. The DSD and DON both emphasized the importance of sitting at eye level with the resident to prevent aspiration and maintain dignity. The facility's policy and procedure on dignity, revised in December 2021, indicated that residents should be cared for in a manner that promotes their well-being and self-esteem, including during dining experiences.
Failure to Document Change of Condition for UTI
Penalty
Summary
The facility failed to complete a Change of Condition (COC) form when a resident developed a urinary tract infection (UTI). The resident, who was admitted with diagnoses including obstructive uropathy and benign prostatic hyperplasia, was administered Bactrim for the UTI over a seven-day period. Despite this treatment, there was no COC form completed to document the change in the resident's condition, which is a necessary communication tool for staff to monitor the resident's health status effectively. Interviews with the Infection Prevention Nurse, a Licensed Vocational Nurse, and the Director of Nursing confirmed that a COC should have been completed to ensure proper monitoring of the resident's UTI. The facility's policies and procedures require licensed nurses to identify, document, and report changes in a resident's condition. However, in this case, the necessary documentation was not completed, potentially impacting the staff's ability to monitor the resident's condition accurately.
Inaccurate PASARR Completion for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of paranoid schizophrenia and major depressive disorder. The resident was initially admitted and later readmitted with these diagnoses, and the Minimum Data Set (MDS) indicated severe cognitive impairment and dependency in daily activities. Despite these conditions, the PASARR I screening inaccurately indicated a negative Level I screening, stating that the resident did not have a serious mental disorder diagnosis and was not prescribed psychotropic medications, which was contrary to the resident's medical records. The Director of Nursing (DON) acknowledged the inaccuracy of the PASARR, noting that the resident was indeed diagnosed with paranoid schizophrenia and was receiving Seroquel, an antipsychotic medication. The facility's policy required accurate completion of PASARRs, but the failure to do so could potentially delay necessary services for the resident. The DON was responsible for ensuring the accuracy of the PASARR, and the discrepancy was identified during a concurrent interview and record review.
Failure to Administer Constipation Medications
Penalty
Summary
The facility failed to provide necessary services and care to two residents, Resident 18 and Resident 45, by not administering medications for constipation as ordered. Resident 18, who was admitted with diagnoses including dementia and major depressive disorder, had not had a bowel movement for five days. Despite having a care plan that included monitoring and recording bowel movements and providing a bowel regimen, the facility did not administer MiraLAX as ordered when Resident 18 had not had a bowel movement in over three days. Interviews with staff, including an LVN and the DON, confirmed that the facility's policy was to administer a laxative if a resident had not had a bowel movement in three days, which was not followed in this case. Resident 45, who was admitted with diagnoses including unspecified dementia and major depressive disorder, also did not receive the necessary medications for constipation. The resident had no bowel movement for five consecutive days, yet medications such as Milk of Magnesia and Dulcolax suppository, which were ordered to be given if no bowel movement occurred in three days, were not administered. The resident's care plan included monitoring bowel movements and providing a bowel regimen, but these interventions were not effectively implemented. Interviews with staff, including a CNA and an LVN, confirmed that the resident's constipation was not properly addressed, despite being on Seroquel, which has constipation as a side effect. The facility's failure to administer the prescribed medications for constipation and to monitor bowel movements as per the care plans and physician orders put both residents at risk for gastrointestinal complications. The staff interviews revealed a lack of adherence to the facility's policy regarding the management of constipation, which contributed to the deficiency in care for both residents.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 25.93% error rate. This deficiency was observed during the medication pass for two residents, where medications were not administered within one hour of the prescribed time as per the facility's policy. The facility's policy, titled 'Administering Medications,' requires medications to be administered within one hour of their prescribed time unless otherwise specified. For Resident 1, the medications Amlodipine, Eliquis, and Hydralazine were scheduled to be administered at 9 a.m. but were given at 10:46 a.m., one hour and 46 minutes late. Resident 1 had a history of acute embolism, thrombosis, transient ischemic attack, and hypertension. The delay in medication administration was confirmed by LVN 1, who acknowledged the increased risk of hypertension, deep venous thrombosis, and blood clotting due to the late administration. Resident 228's medications, including Escitalopram, Amlodipine, Heparin, and Hydralazine, were also administered late. The scheduled times were 7 a.m. for Escitalopram and 8 a.m. for the other medications, but they were administered at 10:57 a.m. Resident 228 had diagnoses of end-stage renal disease, bipolar disorder, and recurrent major depressive disorder. LVN 1 confirmed the late administration and acknowledged the increased risk of hypertension, thrombosis, mood changes, and hospitalization. The Director of Nursing also confirmed the late administration and stated that the medication orders were incorrectly entered with earlier times than intended.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors by not administering their prescribed medications within the required timeframe. Resident 1, who had a history of acute embolism, thrombosis, and hypertension, did not receive Amlodipine, Eliquis, and Hydralazine within one hour of the prescribed time. The medications were scheduled for 9 a.m. but were administered at 10:46 a.m., one hour and 46 minutes late. This delay was observed during a medication administration review, and the Licensed Vocational Nurse (LVN) acknowledged the error, noting the increased risk of hypertension and other complications due to the delay. Similarly, Resident 228, who had diagnoses including end-stage renal disease and bipolar disorder, did not receive Amlodipine, Escitalopram, Heparin, and Hydralazine within the prescribed timeframe. The medications were scheduled for 7 a.m. and 8 a.m. but were administered at 10:57 a.m., nearly four hours late for some medications. The LVN confirmed the late administration and recognized the potential risks associated with the delay, including hypertension and mood changes. The Director of Nursing (DON) confirmed that the medications should have been administered within one hour of the prescribed time and acknowledged the late administration as a medication error. The facility's policy on administering medications, dated April 2019, requires medications to be administered within one hour of their prescribed time. The DON noted that the medication orders were incorrectly entered with earlier times than intended, contributing to the late administration. The facility's policy on medication errors, dated June 2022, defines medication errors as administration at the wrong time.
Inaccurate Documentation of Resident's Refusal of Splint
Penalty
Summary
The facility failed to accurately document the refusal of a right elbow splint by a resident with significant medical conditions, including cerebral infarction, aphasia, hemiparesis, and an acquired absence of the left leg above the knee. The resident, who was severely impaired in daily decision-making and communication, was observed not wearing the right elbow splint on a specific date, despite physician orders for its application. The RNA records inaccurately indicated that the splint was applied on that date, although the resident had refused it. During observations and interviews, it was confirmed that the resident refused the right elbow splint on two consecutive days. The RNA staff acknowledged the refusal but failed to document it correctly in the RNA records. The Director of Staff Development noted that the RNA records should have indicated the refusal to ensure proper communication with the resident's family or physician for further recommendations. The facility's policy on nursing documentation emphasized the importance of accurate documentation based on the resident's condition.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the inappropriate prescription of antibiotics to a resident. The resident, who was admitted with diagnoses including diabetes mellitus and cerebral infarction, was prescribed Ciprofloxacin despite not meeting the LOEB's criteria for antibiotic use. The Infection Prevention Nurse (IPN) acknowledged that the resident did not meet the criteria and that the primary physician insisted on the prescription. However, the IPN did not escalate the issue to the facility's Medical Director, which was a necessary step according to the facility's policy. The Director of Nursing (DON) confirmed that the resident should not have been prescribed Ciprofloxacin, as they did not meet the criteria outlined in the facility's antibiotic stewardship policy. The facility's policy mandates that all antibiotic use should be reviewed by the infection preventionist to ensure appropriate use, which was not adhered to in this case. This oversight had the potential to contribute to antibiotic resistance and inappropriate antibiotic use, as unnecessary medications were administered without proper justification.
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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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