The Ellison John Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, California.
- Location
- 43830 10th Street West, Lancaster, California 93534
- CMS Provider Number
- 555904
- Inspections on file
- 88
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at The Ellison John Transitional Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and fluctuating decision-making capacity developed new wandering behavior, repeatedly entering another resident’s room. Although another resident reported this to an LPN, no Change of Condition evaluation was completed, and there was no documentation that the MD or the resident’s representative were notified, contrary to facility policy. Required 72-hour, every-shift monitoring and SBAR documentation following this significant change in condition were not recorded on multiple shifts, resulting in undocumented assessment and monitoring of the resident’s new wandering behavior.
A resident with diabetes, glaucoma, generalized weakness, and intact cognition required maximum assistance with ADLs per the MDS, but the ADL care plan only stated that assistance with eating was needed and did not specify the type or level of help, despite the resident’s visual impairment and documented need for maximum assistance. Family reported that staff delivered meal trays, briefly described the contents, and left the resident to eat alone, with some items not actually present on the tray. The resident had PRN orders for bisacodyl and MOM for constipation, and bowel records showed several days without bowel movements, yet the MAR showed these medications were not administered as ordered, contrary to the constipation care plan intervention to give medications as ordered. The MAR also documented that the resident refused insulin glargine on two occasions, but no care plan was developed to address this treatment refusal, even though facility policy requires the comprehensive care plan to identify declined services, associated risks, and IDT efforts when a resident refuses treatment.
A resident with DM, HTN, and other conditions did not receive PRN bisacodyl suppositories or MOM despite documented days without bowel movements, and one bisacodyl dose that was given was not recorded on the MAR. The resident also had ordered daily glargine insulin that was not administered on days when blood glucose levels were above the hold parameter, and scheduled enoxaparin, metformin, and metoprolol were repeatedly given outside the facility’s required one-hour window around the scheduled times. Interviews with an LVN and the DON confirmed that these actions did not follow physician orders or facility medication administration policies.
Two residents who were frequently incontinent and required maximum assistance for ADLs reported delayed responses to their call lights, including one episode where a resident experiencing vomiting waited 30–60 minutes without staff response and another who often had to involve a family member when evening-shift staff did not respond promptly for incontinent care. The DON acknowledged that delayed call light response can delay meeting residents’ needs, and facility policy states that residents must be able to summon staff through the call system.
A resident with multiple medical conditions, including DM, generalized weakness, and glaucoma, experienced vomiting, prompting an RN to notify the resident’s POA, who requested COVID-19 testing. The RN performed the test, which was negative, but neither the SBAR nor progress notes contained documentation that the POA was informed of the result. In interviews, the POA reported not being told the outcome, and staff, including an LVN and the RN, acknowledged there was no record of notification, despite facility policy requiring documentation of communication with the resident representative.
A resident with a history of intracerebral hemorrhage, DM, and generalized weakness, who was cognitively intact but required maximum assistance with ADLs, had a COC form completed after a bisacodyl suppository was inserted into the frontal private area. The COC lacked documentation of the date of the last bowel movement to support the intervention, despite facility policy and SBAR charting instructions requiring complete documentation or use of N/A when information is not applicable. A family member reported the suppository was inserted in the wrong area, and staff acknowledged the COC was incomplete and did not provide adequate clinical justification in the medical record.
A resident with type 2 DM and severely impaired cognition had physician orders for blood glucose checks every four hours and for shift-by-shift monitoring and documentation of hypoglycemia signs and symptoms. Over a 21‑day period, the MAR and blood sugar summary showed glucose levels were recorded only four times daily instead of every four hours, with no evidence of the ordered monitoring. During a hypoglycemic change of condition with labored breathing, altered level of consciousness, and a documented blood sugar of 45 mg/dL, the resident’s hypoglycemia signs and symptoms were recorded on a COC form but not documented in the MAR. The LVN and DON acknowledged that the required monitoring and documentation were not completed as ordered and that undocumented care was considered not done, contrary to facility policies on diabetes management and clinical documentation.
A resident with type 2 DM and severely impaired cognition experienced hypoglycemia with labored breathing and altered consciousness, and staff administered glucagon 1 mg IM and glucose gel 40% during the event. The glucose gel had been previously discontinued and was given without a current physician order, while the glucagon administration, though ordered, was not documented on the MAR, only on the change-of-condition form. Interviews with an RN, an LVN, and the DON confirmed that the medication was given without an active order and that required MAR documentation for the glucagon dose was missing.
A resident with multiple medical conditions did not receive a prescribed second dose of permethrin cream for suspected scabies because the medication was not available at the time of administration. The nurse reordered the medication, but it was delivered after the resident had been discharged. Facility policy requires medications to be administered as ordered, but this was not followed, resulting in an incomplete treatment regimen.
A resident with multiple chronic conditions did not receive 14 prescribed medications at a scheduled time, and was also given a blood pressure medication outside of ordered parameters, with no documentation or physician notification for these deviations.
Two residents did not receive care according to physician orders and professional standards. One resident experienced delayed administration of glaucoma eye drops and was not provided with the correct size of incontinence briefs, resulting in discomfort and the need for family intervention. Another resident missed scheduled IV antibiotic doses due to lack of IV access, and staff failed to notify the physician about the missed doses or the absence of IV access.
Two residents experienced significant medication errors when a Bisacodyl suppository was administered via the wrong route and a full course of Ertapenem IV antibiotics was not completed as ordered. These errors were confirmed through record review and staff interviews, and were not in accordance with facility policy or physician orders.
A resident admitted with two right abdominal JP drains and multiple complex diagnoses did not have these drains addressed in their care plan. Despite requiring maximal assistance and having intact cognitive function, the care plan lacked measurable objectives and interventions for JP drain management. Staff interviews and policy review confirmed the omission, which placed the resident at risk for insufficient care related to the drains.
A resident with multiple diagnoses, including cellulitis and cancer, did not receive a physician-ordered CBC with differential after the initial blood sample was unusable. Facility staff did not follow up with the laboratory to ensure the test was completed, resulting in the test not being performed as required by facility policy.
A resident with multiple complex medical conditions was admitted with a PIV catheter, but the facility failed to document the removal of the initial catheter and the placement of a new one. Staff interviews confirmed that required details such as timing, site, and reason for catheter changes were missing from the medical record, contrary to facility policy.
A resident with a history of falls and cognitive impairment repeatedly attempted to get out of bed unassisted, but staff failed to ensure the bed alarm was functioning and did not provide adequate supervision or timely intervention, resulting in a severe fall and injury. After the fall, the resident was moved without an RN assessment, contrary to policy. Another resident at high risk for falls was also found with a disconnected bed alarm, and staff did not check its functionality during their rounds.
A resident with multiple health conditions experienced a fall resulting in injuries and a physician-ordered emergent transfer to the hospital. However, a family member refused immediate transfer, causing a 30-minute delay before 911 was called. Facility staff did not notify the physician of the delay, despite policy requiring such notification when treatment is altered or refused.
A resident with intact cognition and multiple neurological diagnoses reported being hit by two CNAs during care. The RN notified the state survey agency and law enforcement within the required timeframe but failed to report the abuse allegation to the Ombudsman as mandated by facility policy and regulations. Staff interviews and policy review confirmed the omission.
A resident with multiple chronic conditions reported numbness and weakness on one side of her face to an RN, who assessed her but did not notify the physician as required by facility policy. The resident continued to experience symptoms and, after reporting them again to another RN, was transferred to the emergency department and diagnosed with Bell's Palsy. The delay in physician notification resulted in delayed care and treatment.
A nurse left a resident's prescribed medication, polyethylene glycol 3350 mixed with water, unattended on the bedside table after forgetting to administer it. The nurse acknowledged the error, and another RN confirmed that medications should not be left unattended, as per facility policy. The resident had multiple medical conditions and was prescribed the medication for bowel management.
A resident with a history of falls and multiple health conditions was admitted without a fall risk assessment being completed as required by facility policy. Staff and the DON confirmed the assessment was missed, despite documentation showing the resident needed significant assistance and was at high risk for falls.
A resident with heart failure and other medical conditions experienced a rapid weight loss, but the facility did not obtain weekly weights as required by the care plan and facility policy. Despite clear documentation and interdisciplinary team instructions to monitor the resident's weight weekly, the next weight was not recorded until almost two weeks later, during which time the resident developed edema and a large weight gain was noted. Facility leadership confirmed that the required weekly weights were not performed, resulting in a delay in care.
A resident with multiple medical conditions experienced symptoms requiring a urinalysis and culture, but the facility failed to ensure the laboratory specimen was picked up and processed. The specimen was collected and stored, but staff did not notify the lab or follow up on the results, and the order was not tracked, resulting in the resident being discharged without the necessary tests completed.
A resident with severe cognitive impairment, epilepsy, and high fall risk was found living in a cluttered room, with multiple boxes, bags, and clothing obstructing the entrance. The clutter, belonging to the roommate, was observed by an LVN and confirmed by the DON, who stated the environment was not comfortable. The resident's care plan required a clutter-free environment due to high fall risk, but this was not maintained.
A resident with a history of neuropathy, malignant melanoma, hypothyroidism, and muscle weakness did not receive prescribed muscle spasm medication after a change in physician orders. An LVN failed to review the updated medication orders, resulting in a delay in administering Cyclobenzaprine when the resident reported muscle spasms. The DON confirmed that medications were not given as ordered, contrary to facility policy.
A resident with a multidrug-resistant E. coli urinary tract infection was placed on contact precautions, but staff failed to post an isolation sign indicating the required PPE at the room entrance, despite facility policy and care plan directives. Staff interviews confirmed the omission and acknowledged that the sign was necessary to inform staff and visitors of the appropriate precautions.
The facility failed to develop comprehensive care plans for residents, including those using CPAP, insulin, and antibiotics, and did not document a resident's preference for female CNAs. This lack of care plans led to potential risks in treatment and unmet resident preferences.
The facility's nursing staff failed to rotate injection sites for insulin and heparin for three residents, leading to potential skin damage and impaired medication absorption. Additionally, a resident did not receive three doses of levothyroxine as ordered, which could affect thyroid function. The Director of Nursing acknowledged these as deficiencies in adherence to professional standards and facility policies.
The facility failed to maintain a safe environment and provide adequate supervision, leading to multiple deficiencies. A resident had unauthorized medication at the bedside, another had a deactivated fall alarm, and several residents had obstructed fall mats. Additionally, post-fall monitoring was not completed for a resident, indicating lapses in safety protocols.
A resident using a home CPAP machine in an LTC facility did not have a physician's order, assessment, or care plan for its use. The CPAP machine and mask were not cleaned according to the manufacturer's guidelines, and staff acknowledged these deficiencies. The resident had diagnoses including COPD, asthma, and obstructive sleep apnea.
The facility failed to accurately account for controlled medications for two residents, leading to discrepancies in documentation. Additionally, a resident with anxiety did not receive alprazolam promptly, and another resident missed doses of levothyroxine, highlighting lapses in medication administration and record-keeping.
A facility failed to respond to a pharmacist's recommendations to limit the duration of PRN lorazepam and define the length of therapy for PRN guaifenesin for a resident with an anxiety disorder. The facility did not act on these recommendations, increasing the risk of inappropriate medication use.
The facility failed to perform gradual dose reductions for psychotropic medications, did not limit PRN lorazepam duration, and used antipsychotics without clear indications. Additionally, the facility did not monitor target behaviors and allowed simultaneous use of two antidepressants without justification, increasing the risk of adverse effects.
The facility failed to rotate injection sites for insulin and heparin for three residents, leading to potential adverse effects. Additionally, a resident did not receive three doses of levothyroxine as ordered. These actions were identified as medication errors by nursing staff and the DON.
The facility failed to maintain safe food storage and preparation practices, as two dented cans were improperly stored with non-dented cans, and an opened bag of graham crackers lacked a date label. The Dietary Manager confirmed these oversights, which could lead to cross-contamination and foodborne illness risk for 128 of 150 medically compromised residents.
A resident with major depressive disorder was prescribed Zoloft, but the facility failed to ensure informed consent was properly documented. The consent form lacked the medication dosage and did not have the necessary consent boxes checked. Interviews with the RN and DON confirmed these omissions, violating the resident's right to informed decision-making.
Two residents in an LTC facility were found to have damaged landing mats, which were not reported or replaced by staff, compromising their homelike environment. Despite being part of fall prevention strategies, the mats remained in disrepair, affecting the residents' quality of life.
A facility failed to ensure a resident was free from physical restraints by not obtaining a physician's order, informed consent, or conducting a restraint assessment for a bed pad alarm. The resident, with intact cognition and high fall risk, was observed with a bed alarm without proper documentation. Staff confirmed the oversight, acknowledging the lack of necessary assessments and consents, contrary to facility policies.
A facility failed to include a dementia diagnosis and the use of quetiapine in a resident's baseline care plan upon admission. This omission increased the risk of not addressing the resident's specific needs related to dementia and potential adverse effects from antipsychotic therapy. The Director of Nursing acknowledged the oversight, highlighting the importance of these details in providing resident-centered care.
A facility failed to ensure the IDT reviewed and revised the care plan for a resident with multiple physical restraints. The resident, who had conditions like spondylosis and osteoarthritis, had a care plan last revised in August 2024, despite requiring quarterly reviews. The care plan included various safety devices, but no interdisciplinary meeting was held for the last quarter of 2024. This oversight was confirmed by staff and contradicted the facility's policy on restraint use, potentially leading to unnecessary restraint use and resident decline.
A resident with type 2 diabetes and muscle weakness required assistance with ADLs, including perineal care. During an inspection, a CNA failed to follow proper hygiene procedures, such as handwashing and using clean washcloths, which could impact the resident's dignity and increase infection risk. The facility's policies were not adhered to, as confirmed by staff interviews.
A resident with hypothyroidism did not receive three doses of levothyroxine as ordered, despite the care plan requiring daily thyroid replacement therapy. The LVN acknowledged the missed doses but did not complete a change in condition or progress note. The DON and ADON were not informed of the missed doses until later, contrary to the facility's policy requiring notification of medication errors.
Two residents with urinary catheters were observed with loops in their catheter tubing, which could prevent urine from flowing freely and increase the risk of UTIs. An LVN confirmed the presence of loops, and the DON emphasized the importance of proper catheter positioning. The facility's guidelines for catheter care were not adhered to, leading to this deficiency.
A resident with a history of diabetes and muscle weakness experienced unnecessary pain during ADL care when a CNA failed to recognize and address their verbalization of pain. Despite the resident's complaints, the CNA continued the task without notifying the CN for pain management. The facility's protocols for pain management were not followed, leading to the resident's discomfort.
A facility failed to reevaluate or discontinue a PRN order for guaifenesin oral liquid for a resident after 10 days, contrary to its policy. The resident, with a history of anxiety disorder and cognitive decline, was prescribed the medication without a stop date. Despite a consultant pharmacist's recommendation to limit the duration, the facility did not respond, increasing the risk of inappropriate medication use.
A resident did not receive timely dental services due to the facility's failure to schedule an appointment despite a physician's order. The resident, with conditions such as rheumatoid arthritis and osteoporosis, requested dental care months prior but did not receive a response. The Social Services Assistant acknowledged the oversight, and the Social Services Director confirmed the lack of documentation and communication regarding the resident's dental care needs.
A resident was served fish, a disliked food, despite clear documentation of their dietary preferences. The resident's dietary profile and meal ticket indicated a dislike for fish, but the oversight occurred, leading to the resident being served fish at lunch. Interviews with staff revealed awareness of the resident's preferences, yet the error was not caught, highlighting a lapse in adherence to the facility's policy of respecting residents' dietary choices.
A facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. In one case, a CNA placed a nasal cannula from the floor onto a resident's bed, risking cross-contamination. In another, a CNA did not perform hand hygiene or wear PPE while caring for a resident on enhanced barrier precautions due to a biliary drain. Both actions were against facility policies and posed infection risks.
A facility failed to transmit a resident's MDS Discharge Assessment within the required timeframe. The resident, who had a fracture, gout, and alcohol abuse, was discharged with home health care services. The MDS was submitted late, potentially affecting billing and quality measures. Interviews with staff confirmed the delay, and the facility's policy requires timely transmission of MDS assessments.
The facility failed to ensure accurate assessments for residents, leading to deficiencies in care planning. One resident's MDS did not reflect a dementia diagnosis despite being prescribed donepezil. Another resident's MDS omitted the use of a CPAP machine, affecting care planning. Additionally, a resident's legal name was incorrectly coded in the MDS, impacting service delivery.
Failure to Document and Monitor Change in Resident Wandering Behavior
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in response to a resident’s new wandering behavior. Resident 1, admitted with diagnoses including type 2 diabetes mellitus, COPD, and cerebral infarction, had a prior Wandering/Elopement Risk Evaluation dated 2/18/2026 indicating no risk for wandering or elopement. The resident’s H&P dated 2/19/2026 documented fluctuating capacity to understand and make decisions, while an MDS dated 2/25/2026 indicated intact cognitive skills for daily decision making. On 3/13/2026, Resident 1 was reported wandering into another resident’s room multiple times, which represented a change from the resident’s prior status. On 3/13/2026, Resident 2, who was cognitively intact, reported that Resident 1 entered her room three times, and stated that Resident 3 reported these incidents to a licensed nurse. LVN 1 confirmed that Resident 3 reported Resident 1 being inside the rooms of Residents 2 and 3 and stated that this wandering behavior was new for Resident 1. LVN 1 reported the incident to the licensed nurse in charge of Resident 1 on the 11 p.m. to 7 a.m. shift. However, there was no Change of Condition (COC) Evaluation form completed for Resident 1 on 3/13/2026, and there was no documented evidence that the attending physician or the resident’s family member were notified of this new wandering behavior, despite facility policy requiring immediate consultation with the physician and notification of the resident representative when there is a significant change in physical, mental, or psychosocial status. Further record review and interviews showed that the facility did not document ongoing assessment and monitoring of Resident 1 following this change in condition. LVN 3 stated that Resident 1’s wandering behavior was a change in condition and that the resident should have been monitored every shift for 72 hours, but Resident 1’s progress notes lacked documentation of monitoring on multiple shifts on 3/14/2026, 3/15/2026, and 3/16/2026. LVN 3 and the DON both acknowledged there was no confirmed documented evidence of monitoring on these identified shifts. The facility’s Documentation Policy required initiation of 72-hour charting for a significant change in physical, mental, or psychosocial status, and the Notification of Changes policy specified use of the SBAR charting form as the documentation of a resident’s change in condition. These policies were not followed for Resident 1’s new wandering behavior.
Failure to Develop and Implement Person-Centered Care Plan for ADL Assistance, Constipation, and Insulin Refusal
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement a complete, person-centered care plan for a resident with multiple medical conditions, including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma, and poor vision. The resident was admitted with a controlled carbohydrate, no-added-salt diet and regular texture with thin liquids. The resident’s MDS showed intact cognitive skills for daily decisions but indicated the resident required maximum assistance from staff for all ADLs and was frequently incontinent of bowel and bladder. The care plan for ADLs, dated 11/10/2025, only stated that the resident required assistance with eating and did not specify what type or level of assistance would be provided, despite the MDS indicating a need for maximum assistance. The glaucoma care plan indicated encouraging independence with ADLs and assisting as needed, but did not clearly identify that maximum assistance with eating was required. Family Member 1 reported that the resident was visually impaired and that staff would deliver the food tray, verbally identify the items on the tray, and then leave the resident to eat independently. FM 1 also stated that some of the foods staff said were on the tray were not actually present. During interviews, LVN 1 and the MDS nurse confirmed that the MDS documented the resident’s need for maximum assistance with eating and that the ADL care plan did not include specific interventions describing the type of assistance to be provided during meals. The MDS nurse and the DON both acknowledged that the care plan for glaucoma and ADLs should have specified that the resident required maximum assistance from staff for eating and that the care plan should have been individualized with specific interventions. Surveyors also found that the facility failed to implement the resident’s care plan for constipation and failed to develop a care plan addressing the resident’s refusal of insulin glargine. The resident had PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia if no bowel movement occurred in three days. Bowel movement records showed no bowel movements on multiple dates, yet the MAR indicated that bisacodyl and milk of magnesia were not administered on those days. LVN 1 confirmed that the resident did not have bowel movements on those dates, that the ordered constipation medications were not given as specified, and that the care plan intervention to administer medications as ordered was not followed. Additionally, the MAR documented that the resident refused insulin glargine on two dates, but there was no corresponding care plan addressing this refusal. LVN 1, the MDS nurse, and the DON all stated that a care plan should have been developed for the resident’s refusal of insulin glargine, consistent with the facility’s policy requiring the comprehensive care plan to identify declined services, associated risks, and IDT efforts when a resident refuses treatment.
Failure to Follow Medication Orders and Timely Administration for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and facility policy for one resident with multiple medical conditions, including diabetes mellitus, sequelae of intracerebral hemorrhage, and generalized weakness. The resident was admitted with PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia (MOM) if no bowel movement occurred in three days. Point of Care bowel movement records showed no bowel movements on several specific dates, yet the Medication Administration Record (MAR) indicated that bisacodyl and MOM were not administered on those days. During interview, an LVN confirmed that the resident had no bowel movements on those dates and that neither bisacodyl nor MOM was given as ordered, and the DON stated that the physician’s orders were not followed and that the medications should have been offered and administered or refusals documented. The facility also failed to ensure accurate documentation and administration of bisacodyl on another date. A Change of Condition note documented that bisacodyl was administered to the resident’s frontal private area on a specific date, but the MAR did not show administration of bisacodyl on that date. The DON stated that an LVN administered the bisacodyl but did not document it on the MAR, and that the ADON later documented the administration because the LVN had not done so. Facility policy required that the person who prepares the dose must be the one who administers it and that the individual who administers the medication must record the administration on the MAR directly after giving the medication, including specific documentation requirements for PRN medications. The facility further failed to follow physician orders for insulin glargine and to administer other scheduled medications within the facility’s required time frame. The resident had an order for daily insulin glargine to be held only if blood sugar was less than 100 mg/dl, but the MAR showed that insulin glargine was not administered on two dates when the resident’s blood sugar readings were above 100 mg/dl. An LVN and the DON both acknowledged that insulin glargine should have been administered on those dates and that it was not. Additionally, audit reports showed that enoxaparin, metformin, and metoprolol, all ordered on specific twice-daily schedules, were administered significantly later than the scheduled times on multiple days. The LVN and DON both stated that medications were supposed to be administered within one hour before or after the scheduled time, and that these medications were given outside that window, contrary to facility policy on timely medication administration. Facility policies on administering medications, preparation and general guidelines, and insulin administration all required that medications be administered in accordance with written prescriber orders, that medications be given within 60 minutes of the scheduled time (except for meal-related orders), and that insulin type, dosage, and administration be verified against the physician’s order. The documented late administrations of enoxaparin, metformin, and metoprolol, the missed doses of insulin glargine when blood sugars were above the hold parameter, the failure to administer bisacodyl and MOM when bowel movement criteria were met, and the failure to document a given dose of bisacodyl on the MAR collectively demonstrate that the facility did not follow its own policies or the physician’s orders for this resident’s medications.
Delayed Response to Call Lights for Resident Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were answered in a timely manner, resulting in delays in assistance for two residents. Resident 1 was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, and generalized weakness, and was documented as alert and oriented with intact cognitive skills but requiring maximum assistance for all ADLs and being frequently incontinent of bowel and bladder. According to the resident’s family member, on one occasion when Resident 1 experienced an episode of vomiting, the resident pressed the call light multiple times to request assistance, but no staff responded for 30 to 60 minutes. Resident 3 was admitted with a right femur neck fracture, generalized muscle weakness, and dysphagia, and had the capacity to understand and make decisions, with the MDS later indicating moderately impaired cognitive skills for daily decisions, maximum assistance needs for toileting and showering, and frequent bowel and bladder incontinence. Resident 3 reported that on the evening shift, staff sometimes took a long time to respond to the call light for incontinent care, and if no one answered, the resident would call a family member to request help. The family member confirmed that the resident often called in the evening when call lights were not answered for incontinence care, prompting the family member to call the facility to ask staff to change the resident’s incontinent brief. The DON acknowledged that delays in responding to call lights can delay meeting residents’ needs and can possibly cause skin breakdown such as pressure ulcers. The facility’s policy on the resident call system stated that the facility is adequately equipped to allow residents to call for staff assistance through a communication system relaying calls directly to staff or a centralized work area from residents’ bedside, floor, or toileting facilities.
Failure to Notify Resident Representative of COVID-19 Test Result
Penalty
Summary
The facility failed to notify a resident’s designated family member and POA of the resident’s COVID-19 test result after the family member specifically requested the test. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma with poor vision, and was documented as alert, oriented, and cognitively intact but requiring maximum assistance with ADLs. On the date of the change in condition, an LVN reported to an RN that the resident had vomited, and the RN notified the resident’s family member, who then requested that the resident be tested for COVID-19. The RN performed the COVID-19 test, which was negative, but there was no documentation in the resident’s medical record that the family member/POA was informed of the result. During interviews, the family member stated she was not informed of the test result, and both the LVN and RN confirmed there was no documentation of notification to the family member, despite acknowledging the importance of doing so, particularly because the test had been requested by the family member. The DON also stated that the RN should have documented that the family member was notified and that accurate and complete medical records and informing the resident and representative are rights. The facility’s Notification of Changes policy indicated that the SBAR form serves as documentation of communication with the physician and resident representative, and that progress notes should be used for other necessary information not on the form.
Incomplete Change of Condition Documentation for Resident Receiving Bisacodyl Suppository
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one of three sampled residents by not fully completing a Change of Condition (COC) document. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, and generalized weakness. A History and Physical dated shortly after admission documented that the resident was alert and oriented to person, place, and time. A subsequent Minimum Data Set indicated the resident’s cognitive skills for daily decision-making were intact and that the resident required maximum assistance for all ADLs. On the date of the documented change in condition, the COC form recorded that a bisacodyl suppository was inserted into the resident’s frontal private area, and the section for the date of the last bowel movement was left blank. A family member reported that a suppository had been inserted in the wrong area. During interview and concurrent record review, an LVN confirmed that the COC did not include the date of the last bowel movement to justify the use of bisacodyl and stated the importance of accurate medical records to ensure appropriate treatment. The DON stated that the responsible LVN should have completed the COC to ensure a complete and accurate medical record. The facility’s documentation policy and SBAR Charting Form instructions require that relevant findings be documented in the clinical record and that all sections of the form be completed, or marked N/A if not applicable.
Failure to Monitor and Document Blood Glucose and Hypoglycemia per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of nursing practice for monitoring and documenting blood glucose and hypoglycemia in a resident with type 2 diabetes mellitus. The resident was admitted with diagnoses including type 2 diabetes, major depressive disorder, and essential hypertension, and had severely impaired cognitive skills for daily decision making per the MDS. Physician orders dated 4/7/2023 required licensed nurses to monitor the resident’s blood glucose every four hours, and orders dated 9/9/2025 required monitoring for signs and symptoms of hypoglycemia each shift, with documentation of the presence or absence of those signs and symptoms in the medical record. The resident’s care plans for hypoglycemic medications and type 2 diabetes directed staff to monitor blood sugar per physician orders and to monitor, document, and report signs and symptoms of hypoglycemia. Record review showed that the resident’s blood sugar was not monitored and documented every four hours as ordered. The MAR for 12/1/2025 to 12/31/2025 contained no evidence that blood sugar checks were performed every four hours for 21 days. The Blood Sugar Summary for 12/1/2025 to 12/21/2025 showed blood sugar levels were taken and documented four times a day instead of every four hours (six times a day). During interview, the LVN confirmed that the documentation did not show every-four-hour monitoring and stated that care not documented was considered not provided. The DON also confirmed there was no documented evidence of blood sugar monitoring every four hours, and acknowledged that the facility failed to ensure the resident’s health status was monitored according to physician orders. The deficiency also includes a failure to document the resident’s hypoglycemia and related signs and symptoms in the MAR during a documented change of condition. On 12/21/2025, an SBAR COC form documented that the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m., and that the resident received intramuscular glucagon and oral glucose gel before transfer to an acute care hospital. However, the DON stated that the resident’s signs and symptoms of hypoglycemia during this change of condition were not documented in the MAR. Facility policies on diabetes care and documentation required monitoring for complications of diabetes, incorporation of physician-ordered blood glucose parameters into the MAR and care plan, identification and reporting of changes in condition such as hypoglycemia, and documentation of relevant findings in the clinical record, which were not followed in this case.
Unauthorized Hypoglycemia Treatment and Missing MAR Documentation
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when staff administered hypoglycemia treatments without proper orders and documentation. The resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and essential hypertension, had a discontinued order for glucose gel 40% as of 1/15/2019 and an active order for glucagon 1 mg IM for blood sugar levels less than 70 mg/dL as of 5/11/2024. The resident’s MDS dated 10/24/2025 showed severely impaired cognitive skills for daily decision making, and the care plan for diabetes, last revised on 12/17/2025, directed licensed nurses to provide diabetes medications according to physician orders and to monitor, document, and report signs and symptoms of hypoglycemia. On 12/21/2025, during a change of condition, the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m. The SBAR Communication for change of condition form documented that the resident received glucagon 1 mg IM and glucose gel 40% and was transferred to an acute care hospital. RN 1 stated she witnessed an LVN administer both glucagon 1 mg and glucose gel 40% during this hypoglycemic episode. LVN 2 confirmed that the glucose gel 40% order had been discontinued and that the resident was given glucose gel without an active physician order. Review of the MAR for December 2025 showed no documented administration of glucagon on the date of the event, despite its use being recorded on the change of condition form. The DON stated that physician orders are required before administering medications and that medications given must be documented on the MAR, and acknowledged the failures to obtain an order for glucose gel and to document the glucagon administration.
Failure to Administer Ordered Medication for Suspected Scabies
Penalty
Summary
A deficiency occurred when the facility failed to administer permethrin external cream as ordered for a resident who was suspected of having scabies. The resident had been admitted and readmitted with multiple diagnoses, including gastrostomy, ADHD, and gastro-esophageal reflux disease. Physician orders were in place for contact isolation, monitoring of skin rashes, and the application of permethrin cream from the neck down to the toes for prophylactic treatment. The order specified that the cream should be applied in the evening, left on for 12 hours, and then washed off in the morning. On the scheduled date for the second application of permethrin cream, the Medication Administration Record (MAR) indicated that the medication was not found and had to be reordered. The nurse involved confirmed that the cream was unavailable at the time and that she reordered it. The Director of Nursing (DON) reviewed the records and confirmed that while the first dose had been administered, the second dose was not given because the medication was not available. The DON also stated that the medication was delivered after the resident had already been discharged home, and the resident did not receive the second treatment as ordered. Facility policy requires that medications be administered as prescribed and within a specified time frame. In this case, the failure to have the medication available and to administer it as ordered resulted in the resident not completing the prescribed treatment regimen. The deficiency was identified through interviews, record reviews, and a review of facility policy, which confirmed that the medication administration did not align with physician orders or facility guidelines.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering prescribed medications as ordered. On one occasion, amlodipine besylate, a medication used to manage blood pressure, was administered to the resident despite the resident's blood pressure being below the parameters specified in the physician's order. The medication was given when the systolic blood pressure was 108, which was below the hold parameter of 120, and there was no documentation explaining the rationale for administering the medication outside of these parameters. Additionally, on another occasion, the resident did not receive a total of 14 prescribed medications at the scheduled administration time. The medications missed included treatments for blood pressure, seizure management, supplements, and other chronic conditions. The Medication Administration Record (MAR) for that day showed that the medications were not signed off as given, and there was no documentation to indicate the reason for the omission, such as resident refusal or difficulty swallowing, nor was there evidence that the physician was notified of the missed doses. The resident involved had a complex medical history, including vascular dementia, hyperlipidemia, hypertensive heart disease, seizures, and hemiplegia following a cerebral infarction. The facility's policy required medications to be administered as prescribed and within a specific time frame, with documentation for any deviations. The lack of documentation and failure to follow physician orders led to the identified deficiency.
Failure to Administer Medications as Ordered and Provide Appropriate Supplies
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, medications were not administered at the times ordered by the physician. Specifically, eye drops prescribed for glaucoma were given several hours after the scheduled administration times on multiple occasions. The facility's own policies required medications to be administered as ordered, and the Director of Nursing confirmed that these delays constituted a treatment delay and a medication administration error. Additionally, the same resident, who was frequently incontinent and required maximal assistance, was not provided with the correct size of incontinent briefs as requested. The resident reported discomfort and was told by staff that the appropriate size was not available, leading the resident's family member to bring personal supplies. Facility documentation confirmed that the correct size was not available at the time of need, and the Director of Nursing acknowledged that care supplies should be readily available to prevent discomfort and potential complications. For another resident with cellulitis, bladder cancer, and heart failure, the facility failed to notify the physician when the resident did not have a peripheral IV catheter in place, resulting in missed doses of prescribed intravenous antibiotics. Progress notes and medication administration records showed that the resident went without IV access and missed scheduled doses, with no documentation of physician notification. The Infection Preventionist and Director of Nursing both confirmed that the lack of notification and missed medication doses disrupted antibiotic therapy, as outlined in facility policy.
Significant Medication Administration Errors Involving Two Residents
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration by facility staff. One resident, admitted with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, had a physician's order for a Bisacodyl rectal suppository to be administered rectally every 12 hours as needed for constipation. However, the suppository was inserted into the vagina instead of the rectum, as confirmed by the resident and documented in the change of condition form. The Director of Nursing acknowledged that this constituted a medication error and noted the potential for delayed treatment and pain. Another resident, admitted with cellulitis of the lower extremity, malignant neoplasm of the bladder, and heart failure, was prescribed a 14-day course of Ertapenem Sodium Injection Solution to be administered intravenously each morning for cellulitis. Review of the Medication Administration Record revealed that on two occasions, there were no staff initials to indicate that the antibiotic was administered as ordered. The Infection Preventionist confirmed the importance of completing the full course of antibiotics and acknowledged that the missed doses represented a failure to follow the physician's order. Facility policies reviewed indicated that medications must be administered in accordance with prescriber orders and professional standards, and specifically addressed the importance of correct route and completion of medication administration. The observed failures in both cases were not in accordance with these policies, resulting in significant medication errors for both residents.
Failure to Develop Comprehensive Care Plan for Resident with JP Drains
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with two right abdominal Jackson Pratt (JP) drains. Despite the resident's complex medical history, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure, and the need for maximal assistance with personal hygiene, showers, and lower body dressing, the care plan did not address the presence or management of the JP drains. This omission was identified through observation, interview, and record review, which confirmed that the care plan lacked measurable objectives and timetables related to the JP drains. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan should be resident-centered and include specific goals and interventions for all resident conditions, but the JP drains were not included. The facility's own policies require the development and implementation of person-centered, comprehensive care plans that address each resident's medical, physical, mental, and psychosocial needs. The failure to include the JP drains in the care plan was acknowledged by staff and was found to place the resident at risk for insufficient provision of care and services related to the JP drains.
Failure to Complete Physician-Ordered CBC with Differential
Penalty
Summary
The facility failed to obtain a complete blood count with differential (CBC with differential) as ordered by the physician for a resident admitted with diagnoses including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure. The resident was receiving antibiotic therapy for cellulitis, and the care plan included administering medications as ordered. A physician's order was placed for a repeat CBC with differential, but the initial blood sample collected was clotted and unusable. Although the physician was notified and a new order for blood collection was placed, the laboratory did not collect the sample over the weekend, and there was no documentation that the facility followed up with the laboratory after the weekend to ensure the test was completed. Interviews with facility staff confirmed that the repeat CBC with differential was not completed for the resident. The Infection Preventionist acknowledged that there was no record of follow-up with the laboratory after the initial failed collection, and the Director of Nursing stated that staff should have ensured the test was completed regardless of laboratory notification. Review of facility policies indicated that laboratory services ordered by physicians should be completed in a timely manner to meet residents' needs, but this was not followed in this instance.
Failure to Document PIV Catheter Placement and Removal
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple diagnoses, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure. Upon admission, the resident had a right antecubital (AC) peripheral intravenous (PIV) catheter in place, as documented in the admission evaluation. However, subsequent reviews of the resident's progress notes revealed inconsistencies and missing documentation regarding the removal and placement of PIV catheters. Specifically, there was no record indicating when and why the initial right AC PIV catheter was removed, nor was there documentation of when a new left forearm PIV catheter was placed. Interviews with facility staff, including an LVN and the DON, confirmed the absence of required documentation related to PIV catheter procedures. The facility's own policy required detailed recording of catheter insertion and removal, including date, time, site, and condition of the IV site, as well as notification of the physician in case of complications. The lack of documentation was acknowledged by staff and had the potential to result in inaccurate medical interventions for the resident.
Failure to Ensure Functioning Bed Alarms and Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents at high risk for falls. One resident, with a history of falls, dementia, muscle weakness, and a recent hip fracture, was repeatedly attempting to get out of bed unassisted. Despite a physician's order and care plan interventions requiring a functioning bed pad alarm and staff supervision, the alarm was not plugged in or functioning at the time the resident attempted to get out of bed. The family-provided companion notified staff multiple times about the resident's attempts to get up, but the assigned LVN did not check the alarm, did not notify the RN, and did not provide additional interventions. The resident subsequently had an unwitnessed fall, resulting in a severe right arm fracture, blunt head trauma, and required hospitalization and surgery. After the fall, the LVN and CNA moved the resident back to bed without waiting for an RN assessment, contrary to facility policy and job descriptions, which require an RN to assess a resident before moving them after a fall. The RN and DON confirmed that this action was not within the LVN's scope of practice and could have contributed to further injury. Interviews with staff and review of facility policies confirmed that the responsibility for fall prevention and supervision remains with facility staff, regardless of the presence of a family-provided companion, who was not medically trained and was not responsible for direct care. A second resident, also at high risk for falls with a history of traumatic brain and bone injuries, was observed with a disconnected bed alarm despite a physician's order and care plan requiring its use. Multiple staff entered the room without checking or ensuring the alarm was functional. The DON acknowledged that the care plan was not implemented and that the pad alarm should be checked for functionality every time staff enter the room. Facility policies reviewed emphasized the need for individualized interventions, adequate supervision, and consistent use of assistive devices to prevent avoidable accidents, all of which were not followed in these cases.
Failure to Notify Physician of Delay in Emergent Transfer After Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the primary physician regarding a delay in transferring a resident to the hospital after a significant change in condition. The resident, who had a history of hip fracture, dementia, osteoporosis, muscle weakness, and previous falls, sustained a fall resulting in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status. The physician was initially notified and ordered an emergent transfer via 911, but the resident's family member refused the immediate transfer and requested to wait until arrival at the facility, causing a delay of approximately 30 minutes before 911 was called. During this period, there was no documented evidence that the physician was informed of the family member's refusal or the delay in executing the transfer order. Interviews with staff, including the RN involved and the Director of Nursing, confirmed that the facility's policy required physician notification when there is a refusal of care or a need to significantly alter treatment, such as delaying an emergent transfer. The staff acknowledged that the physician should have been notified of the delay, but this did not occur. Facility policies reviewed indicated that the physician must be informed of accidents resulting in injury, significant changes in treatment, and decisions to transfer or discharge a resident. The failure to notify the physician of the delay in transfer, as required by policy, resulted in a deficiency related to the immediate notification of the resident's physician in situations affecting the resident's health and treatment.
Failure to Timely Report Abuse Allegation to Ombudsman
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the Ombudsman as required by its abuse policy. A resident with diagnoses including Parkinson's disease, hemiplegia, and hemiparesis, and with intact cognition, reported to a registered nurse that two certified nursing assistants had hit her during hygiene care and repositioning. The incident was documented in the resident's records, and the nurse reported the allegation to the state survey agency and local law enforcement within two hours, but neglected to notify the Ombudsman. The facility's policy and state and federal regulations require that all allegations of abuse be reported to the Ombudsman within two hours by phone and followed by a written report within 24 hours. Interviews with facility staff, including the registered nurse and the director of nursing, confirmed that the Ombudsman was not notified of the abuse allegation as required. The director of nursing, acting as the abuse coordinator, acknowledged that the failure to notify the Ombudsman was a deviation from both facility policy and regulatory requirements. The omission was also confirmed through review of the facility's abuse prohibition and prevention program policy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident reported numbness and weakness on the right side of her face. The resident, who had diagnoses including chronic respiratory failure, type 2 diabetes, ventilator dependence, and hypertensive heart disease, was cognitively intact and dependent on staff for activities of daily living. On the evening in question, the resident informed a registered nurse (RN) of her symptoms. The RN assessed the resident for signs of stroke, found none, and educated the resident on stroke symptoms, but did not notify the physician. The RN later acknowledged that she should have contacted the physician but failed to do so at the time. The resident continued to experience symptoms over the weekend and reported them again to a different RN, who then notified the physician and arranged for the resident to be transferred to the emergency department, where she was diagnosed with Bell's Palsy. The facility's policy required timely notification of the physician and resident representative in the event of significant changes in a resident's condition. The Assistant Director of Nursing confirmed that the physician should have been notified immediately and that there was a delay in care and treatment.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) left a resident's medication, specifically polyethylene glycol 3350 powder mixed with water, unattended on the resident's bedside table. The LVN had administered all other scheduled medications but forgot to give the mixed medication, leaving it in the room while stepping away to the nurse station. Upon returning, the LVN realized the medication had not been administered and acknowledged that medications should not be left unattended. This was confirmed during an interview, where the LVN stated that leaving medications unattended could result in other residents taking the medication or the intended resident not receiving it. The resident involved had been admitted with acute respiratory failure, type 2 diabetes mellitus, and benign prostatic hyperplasia, and was prescribed the medication for bowel management. The facility's policy on administering medications required that medications be given safely and timely, following the pour, pass, chart standard of practice. Both the LVN and a registered nurse (RN) interviewed confirmed that the medication should not have been left unattended and that the facility failed to ensure the resident received all scheduled medications before the nurse left the room.
Failure to Complete Fall Risk Assessment Upon Admission
Penalty
Summary
A resident with a history of falls, diabetes mellitus, muscle weakness, and anemia was admitted to the facility. Upon admission, the facility failed to complete a fall risk assessment for this resident, despite the facility's policy requiring such an assessment within 2 to 24 hours of admission. The resident's records, including the Minimum Data Set, indicated a need for moderate to maximal assistance with daily activities and transfers, and documented a history of falls. The care plan, revised over a month after admission, identified the resident as being at risk for recurrent falls and injury due to deconditioning and balance problems. During interviews, both a registered nurse and the Director of Nursing confirmed that the fall risk assessment was not completed upon admission, acknowledging that the assessment is necessary to identify residents at risk and to initiate appropriate fall prevention interventions. The facility's policy on fall management specifically requires a fall risk evaluation for each new admission, and the omission in this case was recognized as a failure to follow established procedures.
Failure to Obtain Weekly Weights After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain weekly weights for a resident who experienced a significant change in condition, specifically a weight loss of 15 pounds in one week. The resident had been admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The care plan, created and revised after the weight loss, included interventions such as weekly weights and monitoring for changes in condition, but these interventions were not consistently implemented. The resident's weight dropped from 157 lbs. to 142 lbs. within eight days, representing a 9.6% loss. Despite the care plan and interdisciplinary team notes indicating the need for weekly weights, the next documented weight was not obtained until nearly two weeks later. During this period, the resident developed edema in both lower extremities and upper arms, and a subsequent weight measurement showed a significant increase, which was not immediately recorded due to concerns about accuracy. The facility's own policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed. Interviews with the ADON and DON confirmed that weekly weights were not performed as required for the resident, and both acknowledged that this lapse could have led to a delay in care. The facility's policy and the care plan both specified the need for weekly monitoring, but the failure to obtain and document these weights resulted in a deficiency related to maintaining adequate nutrition and hydration for the resident.
Failure to Provide Timely Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide timely laboratory services for one resident who was admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The resident developed dysuria, and a physician ordered a urinalysis (UA) and culture and sensitivity (C/S) to be completed. The initial urine specimen collected was found to be insufficient, prompting a repeat order for UA and C/S. Although a nurse collected the repeat specimen and placed it in the facility's refrigerator, the laboratory had already made its scheduled pick-up earlier that day. No staff member called the lab to inform them that the specimen was ready, nor did anyone follow up to ensure the specimen was picked up or to obtain the results. The order for the laboratory test subsequently fell off the facility's tracking system, and the resident was discharged without the ordered labs being completed. Interviews with the DON and the nurse involved confirmed that there was no verification of specimen pick-up or follow-up on the test results. The facility's policies required timely completion and reporting of laboratory services, but these procedures were not followed in this instance, resulting in the deficiency.
Failure to Maintain a Clutter-Free, Homelike Environment for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's room was free from clutter, as required to maintain a safe, clean, and homelike environment. During an observation with an LVN, multiple boxes, bags, blankets, and clothing were found cluttering both sides of the room entrance. The items belonged to the resident's roommate. The Director of Nursing confirmed that the resident was cognitively impaired and acknowledged that a reasonable person would not feel comfortable in such a cluttered environment. The resident involved had a history of epilepsy, schizophrenia, and muscle weakness, and was assessed as having severely impaired cognitive functioning. The resident required maximal assistance with lower body dressing and was dependent for eating, personal hygiene, and toilet transfers. The care plan indicated a high risk for falls and injuries, with specific instructions to keep the environment free from obstruction. Despite these documented needs, the room remained cluttered, contrary to the facility's policy and procedure for maintaining a homelike environment.
Failure to Administer Muscle Spasm Medication as Ordered
Penalty
Summary
A resident with diagnoses including neuropathy, malignant melanoma, hypothyroidism, and muscle weakness was admitted with intact cognitive function and the capacity to make decisions. The resident had a physician's order for Baclofen 5 mg three times daily for muscle spasms, which was discontinued, and a new order for Cyclobenzaprine HCl 10 mg every 8 hours as needed for muscle spasms was issued. On the day following the medication change, the resident reported experiencing muscle spasms and discomfort, stating he had not received his muscle spasm medication since the previous night. The LVN present was unaware of the new Cyclobenzaprine order and did not review the complete order summary, resulting in the resident not receiving the prescribed medication when requested. The medication administration record confirmed that Cyclobenzaprine was not administered until several hours after the resident's complaint. The DON acknowledged that the facility failed to administer medications and treatments as ordered by the physician, attributing the delay to the LVN's failure to review the updated orders. Facility policy required medications to be administered as prescribed and in accordance with written orders, which was not followed in this instance.
Failure to Post Isolation Sign for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not posting an isolation sign near the room of a resident who was under contact precautions for a multidrug-resistant E. coli urinary tract infection. The resident's care plan and physician's orders specified the need for contact isolation and the posting of a precaution sign, in accordance with facility policy. However, during observation, although an isolation caddy with PPE was present on the door, there was no sign indicating the type of precautions or required PPE for entry. Interviews with facility staff, including an LVN, the Infection Preventionist Assistant, and the Director of Nursing, confirmed that an isolation sign should have been posted to alert staff and visitors of the necessary precautions. The facility's own policy also required such signage to inform staff of the type of precaution required. The absence of the sign was acknowledged by staff as a failure to follow protocol, which could have led to improper use of PPE and increased risk of infection transmission.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident 29, who was admitted with chronic obstructive pulmonary disease, asthma, MRSA infection, type 2 diabetes mellitus with hyperglycemia, and cellulitis, was observed using a CPAP machine without an order, assessment, or care plan in place. Additionally, there was no care plan for the administration of Humulin R, a hypoglycemic medication, for Resident 29, despite the resident being on a high-risk drug class. The lack of care plans for these treatments meant that staff were not guided on the safe use and monitoring of these interventions, potentially compromising the resident's care. Resident 73, who was admitted with a flaccid neuropathic bladder, chronic viral hepatitis C, and acute respiratory failure, was prescribed Cephalexin, Ciclopirox, and Lotrimin AF cream. However, there were no care plans developed for these medications, which are crucial for monitoring side effects and ensuring safe administration. The absence of care plans for these medications indicated a failure to communicate the necessary interventions and goals to the healthcare team, which could affect the resident's treatment outcomes. Resident 52, diagnosed with type 2 diabetes mellitus with hyperglycemia and dysphagia, was receiving Insulin NPH without a corresponding care plan. This oversight meant that the staff lacked guidance on the safe administration and monitoring of the insulin, which is critical for managing the resident's diabetes. Additionally, Resident 97, who expressed a preference for only female CNAs due to fear of male caregivers, did not have this preference documented in a care plan. This lack of documentation led to a failure in respecting the resident's preferences, which could negatively impact their psychosocial well-being.
Plan Of Correction
Social Services provided a list of residents with known preferences for a specified gender of caregivers on 3/18/2025. Copies of the audits were provided to the DON for further review and analysis. A total of 65 residents' records were analyzed. The IDT developed and implemented person-centered care plans for 9 of 65 residents who required person-centered care plans for use of insulin, CPAP therapy, or who had expressed preferences for a specified gender of certified nurse assistant. Residents identified without interventions specific to CPAP, use of insulin, and preferences for specified caregivers. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the licensed nurses and IDT on or before 3/20/2025, re: the facility policy and procedure "Develop - Implement Comprehensive Care Plans," to ensure the development of a person-centered care plan is completed with person-specific interventions to address use of CPAP machines, use of insulin, and known preference for a specific gender of certified nurse aides. The interdisciplinary team will review the care plans of newly admitted residents and residents with physician order changes from the prior business day during the clinical meeting to ensure care planning for the preference for the use of insulin, CPAP machines, and known preferences for gender-specific certified nurse aides are developed and implemented to ensure staff have guidelines to care for residents. D. How the facility plans to monitor its performance to make sure solutions are sustained; The interdisciplinary team, led by the MDS Coordinator, completes a discipline-specific assessment of each resident at the time of admission to ensure person-centered care planning is present; to provide appropriate monitoring interventions. Care plans will be monitored and updated to reflect current interventions on admission, within 21 days, quarterly, annually, with significant change, as indicated. The MDS Coordinator/designee will report trends identified in the interdisciplinary team audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.
Failure to Rotate Injection Sites and Administer Medication as Ordered
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating the subcutaneous administration sites for insulin and heparin for three residents. Resident 65, who has type 2 diabetes mellitus and requires insulin, had multiple instances where insulin was administered in the same area, contrary to the physician's orders and facility policy. This practice was confirmed by both the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the failure to rotate injection sites could lead to adverse effects such as bruising and skin conditions. Similarly, Resident 29, who was on heparin for deep vein thrombosis prophylaxis and insulin for diabetes, also experienced repeated administration in the same site. The Registered Nurse and Director of Nursing both noted the importance of rotating injection sites to prevent skin damage and ensure proper medication absorption. Despite the facility's policy and manufacturer's guidelines, the staff did not comply with the required rotation of injection sites. Additionally, Resident 52, who has type 2 diabetes and cognitive impairments, received insulin injections repeatedly in the same area. The Registered Nurse and Director of Nursing confirmed the oversight, emphasizing the risk of skin damage and impaired medication absorption. Furthermore, Resident 197 did not receive three doses of levothyroxine as ordered, which could affect thyroid function. The Director of Nursing acknowledged this as a medication error, highlighting the need for adherence to prescribed medication schedules.
Plan Of Correction
F 658 The DSD/designee will complete weekly audits of residents receiving subcutaneous injections to ensure licensed nurses are rotating injection sites routinely to ensure residents do not experience tissue damage to the extent possible. The DSD/designee will run an injection administration audit through PCC weekly to audit. Concerns identified will be reported to the Director of Nursing for further review, analysis, and follow-up. The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly for the purpose of process improvement. The Director of Nursing will monitor the DSD audits of resident subcutaneous injection sites by licensed nurses to ensure sites are rotated to mitigate tissue damage to the extent possible and to identify continued compliance or the need for further education or progressive disciplinary action through use of the injection administration audit on PCC. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during acceptable timeframe for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. Trends identified in the injection site rotation audits will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date 3/25/2025 F 658 F 658 F 658 F 658 F 658 F 658 F677 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1 received one-to-one re-education regarding grooming and personal hygiene including cleaning the overbed table before and after placing washcloths onto it, hand hygiene prior to and following providing grooming assistance to the residents, and removing gloves prior to leaving the room to reduce the potential adversely affecting residents' psychosocial well-being. Certified Nurse Assistants are performing hand hygiene prior to donning and following doffing of gloves. Resident 65 is receiving grooming care in a manner that promotes his psychosocial well-being. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: All residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The DSD/designee will re-educate nursing staff on the facility's policy "Activity of Daily Living" with emphasis on hand hygiene prior to and after.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for several residents. For one resident, two tubes of triamcinolone acetonide cream were left unattended at the bedside, despite the resident not having an order for the medication and not being evaluated for self-administration. This oversight was observed by multiple staff members, including a CNA and an LVN, who acknowledged the error but did not take immediate action to rectify it. The presence of the cream posed a risk of self-administration and potential adverse reactions. Another resident, who was at high risk for falls, had a floor alarm that was not activated, leaving the resident unattended and vulnerable to falls. The RN responsible for the resident admitted to turning off the alarm and leaving the resident without supervision, which was against the facility's policy. This lapse in supervision could have resulted in a fall and subsequent injury to the resident. Additionally, the facility failed to ensure that fall mats were free from obstructions for several residents. Observations revealed that furniture and medical equipment were placed on top of fall mats, increasing the risk of injury if a resident were to fall. Furthermore, the facility did not complete post-fall monitoring for a resident as per policy, missing several shifts of documentation and monitoring after a fall incident. These deficiencies highlight a lack of adherence to safety protocols and procedures designed to protect residents from avoidable accidents.
Plan Of Correction
B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with the use of pad alarms, landing mats, and medications left unattended at the bedside are potentially affected by the facility practice. The Director of Nursing/designee audited the rooms of residents who use alarms and landing mats to ensure alarms were turned to the on position when the resident is using the device and to ensure furniture or other items are not obstructing the landing strip on 2/27/2025. Five other patients were affected, and the furniture was moved so that it was not obstructing the mat on 2/27/2025. The Charge Nurse audited all resident rooms to identify residents with unattended medications at the bedside on 2/24/2025. No other affected residents were found. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development will re-educate the nursing staff on 3/18/25 the facility policy and procedure, "Accidents and Fall Management," with emphasis on the requirements to: 1. Medications should not be left at the bedside in the absence of residents assessed and approved for self-administration of medications. 2. Floor pad alarms should be in the on position when the resident is in bed. 3. Liquids on the floor are everyone's responsibility and should be cleaned by the appropriate personnel when seen, and a wet floor sign should be placed over the wet area. 4. Furniture should be clear of fall mats to reduce the potential for the furniture to obstruct a resident's fall. 5. Post-fall assessments should be completed following each episode of falling for residents. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Accident Management," with emphasis on resident monitoring, activating alarms, not leaving medications at bedside, and attending to spills on the floor for safety. The Registered Nurse Supervisors will complete walking rounds during their assigned shifts at the beginning of their shifts to ensure resident interventions to reduce falls and/or reduce injury with falling are implemented, including ensuring alarms are activated and that furniture or other obstructions are not blocking the mats. They will also identify if residents have medications at their bedside. The Administrator revised the Management Team's rounding tool to include identification of medications at the bedside and unsafe hazards, including fluid on the floor, alarms not activated, landing strips with obstructions, and medications at the bedside. Management team consists of all department heads with room rounds. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Management Team will monitor their assigned resident rooms five times weekly to ensure compliance with medications, landing mats, alarms, and fluid spills for the safety of all residents. The DSD will complete safety rounds daily during routinely scheduled work hours to ensure resident safety interventions are implemented, including proper functionality of pad alarms, placement of landing mats, and no spills on the floors. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses and certified nursing assistants' performance through direct observation, Department Manager audits, and DSD rounds; and provide re-education or progressive disciplinary action as indicated. The Director of Medical Records/Designee will audit nurses' follow-up charting daily after a fall. The Administrator will conduct routine rounds each day during routinely scheduled work hours to ensure residents are supervised and safety interventions are activated, without obstructions, and floor signs are placed where spills have been cleaned. The DON/designee will report trends identified in resident care plans, assessment, supervision, and safety intervention observations and audits to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F 689 F 689 F 689 F 689 F 690 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 83's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or a loop to reduce the potential for development of urinary tract infection on 2/26/2025. Resident 53's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or loop to reduce the potential for development of urinary tract infection on 2/26/2025. The DON audited Resident 83 and Resident 53's changes in condition from 2/1/2025 through 2/26/2025 to identify if either resident developed a urinary tract infection. Neither resident experienced a UTI in the month of February.
Failure to Ensure Safe Use of CPAP Machine
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident using a home CPAP machine. The resident, who was admitted with diagnoses including COPD, asthma, and obstructive sleep apnea, did not have a physician's order for the use of the CPAP machine in the facility. Additionally, there was no assessment of the CPAP machine's integrity, no monitoring of the resident's respiratory condition or response to therapy, and no care plan that included interventions for CPAP therapy. Observations and interviews revealed that the resident's CPAP machine and mask had not been checked or cleaned according to the manufacturer's guidelines, which included daily cleaning of the mask and tubing. The resident confirmed that the mask and tubing had not been changed for several weeks. The facility's staff, including a registered nurse and a respiratory therapist, acknowledged the lack of a physician's order, assessment, and care plan for the CPAP machine, as well as the failure to clean the equipment as required. The Director of Nursing and the Infection Preventionist also confirmed these deficiencies, emphasizing the importance of having a physician's order, a care plan, and proper cleaning procedures to prevent respiratory infections. The facility's policies and procedures, as well as the CPAP machine's user manual, outlined the necessary steps for safe and effective use of the CPAP machine, which were not followed in this case.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 29's physician assessed the use of the CPAP machine and provided orders for its use and monitoring. The licensed nurse transcribed the physician order for the use and monitoring of Resident 29's CPAP machine on 2/26/2025. The Director of Maintenance evaluated the CPAP machine's safety and integrity on 2/26/2025. The licensed staff are monitoring Resident 29's use of CPAP machine daily and documenting the monitoring in the treatment administration record. The CPAP machine is cleaned routinely per manufacturer's guidelines by the Licensed Vocational Nurses. The IDT developed and initiated a care plan for the use of Resident 29's CPAP including interventions for assessment and monitoring of Resident 29's respiratory status and care of the CPAP machine on 2/26/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents using home CPAP machines are potentially affected by the facility practice. The Assistant Director of Nursing audited all residents who use CPAP machines. A total of 3 residents use CPAP machines. 0 of 3 residents CPAP machines were brought from home. No other residents identified affected by the facility practice. The IDT audited care plans of residents who use a CPAP machine for respiratory conditions to ensure interventions including an assessment, physician order, monitoring and cleaning were present on 2/26/2025. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the nursing staff on or before 3/21/2025, re: the facility policy and procedures, Care Planning, with emphasis on residents with CPAP therapy must have person-centered interventions based on the assessment including evaluation of the safety and integrity of a CPAP machine, when brought from home, No Smoking sign at the resident's door, tubing and mask materials, routine evaluation of respiratory condition through pulse oximeter and routine cleaning per manufacturers guidelines for the CPAP machine. The Interdisciplinary Team will evaluate newly admitted residents for to identify residents with CPAP therapy to ensure the completion of an assessment, physician order and comprehensive person-centered care plan with interventions for CPAP therapy, routine cleaning of the mask and replacement of the tubing, and cleaning of the CPAP machine. Charge nurses will complete routine pulse oximetry each shift of residents with CPAP machines. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Infection Prevention Nurse/designee will monitor residents who use CPAP therapy to ensure cleanliness of the mask, tubing and machine per manufacturer's guidelines to reduce the risk of residents developing respiratory infection. The Charge Nurse will monitor the residents' respiratory health, assess the resident's pulse oximetry and document in the medication administration record each shift. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses' performance through observation and IPN reports; and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in CPAP therapy to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 --- F697 Pain Management CFR(s): 483.25(k) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The licensed nurse completed a pain assessment of Resident 65 to ensure current pain management program is effective on 2/24/2025. CNA 1 received 1:1 re-education on the facility procedure to report resident complaints of pain to the charge nurse for further evaluation on 2/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents cared for by certified nurse assistant 1 are potentially affected. The Charge Nurse interviewed residents cared for by CNA 1 on 2/24/2025 and completed a pain assessment in the medication administration record to identify residents who had unreported complaints of pain. No other residents had complaints of pain that were not conveyed to the charge nurse. No other residents were affected by the facility practice.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately account for controlled medications, affecting two residents. For Resident 87, a discrepancy was found in the Drug Control Receipt Record for clonazepam, where the physical inventory contained one less dose than recorded. LVN 4 admitted to administering the missing dose but failed to document it due to being distracted by other tasks. Similarly, for Resident 93, a discrepancy was noted with lorazepam, where the medication card contained one less dose than recorded. LVN 3 acknowledged administering the dose but forgot to sign it out, highlighting a lapse in maintaining accurate records for controlled substances. In another incident, the facility failed to administer alprazolam to a resident who requested it for anxiety. Resident 347, who was newly admitted with a diagnosis of generalized anxiety, requested the medication at 6 a.m. but did not receive it until after 10 a.m. LVN 6 and LVN 7 both failed to ensure the medication was administered promptly, resulting in a delay that could have exacerbated the resident's anxiety. The facility's policy for timely administration of as-needed medications was not followed, as confirmed by the Director of Nursing. Additionally, the facility did not administer three doses of levothyroxine to Resident 197 as ordered. The resident, diagnosed with hypothyroidism, reported not receiving the medication consistently since admission. A review of the Medication Administration Record revealed that three doses were not administered, which could affect the resident's thyroid function. LVN 1 confirmed the discrepancy and acknowledged the importance of administering medications as ordered to manage the resident's condition effectively.
Plan Of Correction
Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents with controlled substances are potentially affected, and residents not receiving medications as ordered by the physician are potentially affected. The Assistant Director of Nursing/designee completed a controlled substance count of controlled medications at the time of the survey on 2/25/2025 to identify potentially affected residents. All controlled substances were compliant during reconciliation, and the deficient practice was isolated to LVN 3 and LVN 4. All residents are potentially affected by not receiving their as-needed medications when requested. Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur; License Nurse 7 was re-educated by the Director of Nursing/designee on 2/25/2025, on the facility policy and procedure, "Medication Administration," with emphasis on administering as-needed medications when residents request such medications. LVN 3 and LVN 4 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure "Administering Medications," with emphasis on the standard of practice pour, pass, chart to ensure medications including controlled substances are signed, reconciled on the narcotic log and medication administration record when the medication is administered. The DSD, as part of the facility's employee orientation, will educate licensed nurses regarding the facility policy and procedure for medication administration, including evaluation of the nurse's competency to pass and reconcile controlled medications, administer medications per physician order, and prompt administration of as-needed medications when residents request the need for such medications. The Director of Staff Development completed a medication pass observation skill competency of LVN 3, 4, 6, & 7 on 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development is responsible for monitoring licensed and certified nurse assistant staff competency during new hire orientation, annually, and as needed when a variance to standard is identified regarding the facility's "Medication Administration" policy and procedure. Competency-related concerns identified by the DSD will be reported to the Director of Nursing for further review and instruction as indicated. The Consultant Pharmacist will conduct random medication pass observation audits of licensed nurses to ensure medication administration practices are consistent with the standard of practice and facility policy and procedure once per month. Results of the pharmacist audits will be provided to the Director of Nursing and reported to the QAA Committee at a minimum, quarterly, for the purpose of process improvement. The Director of Nursing/designee will report significant findings identified in the medication administration skill competency audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 755
Failure to Respond to Pharmacist's Recommendations on PRN Medications
Penalty
Summary
The facility failed to respond to the consultant pharmacist's recommendations regarding the medication regimens of a resident, identified as Resident 101. The pharmacist recommended limiting the duration of PRN lorazepam to 14 days or defining a specific length of therapy, as well as defining the length of therapy for PRN guaifenesin oral liquid. These recommendations were made on 11/30/2024 and 12/31/2024, respectively. However, the facility did not act upon these recommendations, as evidenced by the lack of new orders or documented responses to the pharmacist's suggestions. Resident 101, who was admitted with an anxiety disorder, was prescribed lorazepam and guaifenesin without defined durations, contrary to the facility's policy. The Director of Nursing acknowledged the failure to limit the duration of these PRN medications, which increased the risk of the resident receiving them inappropriately. The facility's policy required the attending physician to address the pharmacist's recommendations by their next scheduled visit, but this was not adhered to, leading to the deficiency.
Plan Of Correction
F756 Drug Regimen Review CFR(s): 483.45(c)(1) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The licensed nurse clarified Resident 101's use of Lorazepam PRN and the consultant pharmacist's recommendation from 11/24/2024 on 2/24/2025. Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with consultant pharmacist recommendations that have not been responded to are potentially affected by the facility practice. The Director of Nursing requested a consultant pharmacist report on 2/28/2025 of recommendations that have not been responded to for the dates 11/1/2024 through 2/28/2025 to ensure the residents' physicians were contacted and a response was received. The consultant pharmacist provided a list of 0 residents recommendations requiring responses. All consultant pharmacist recommendations were completed. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Nursing revised the facility system for responding to the consultant pharmacist recommendations and filing the MRR in the resident record when an MRR is completed by the consultant pharmacist. The Director of Nursing receives and reviews the pharmacy recommendations from the pharmacist monthly. A copy of the MRR is maintained by month in the DON office. The Nurse Supervisor will receive a copy of the recommendations for timely completion. When completed, the nurse supervisor will file the MRR in the resident's record and provide a copy to the Director of Nursing for review. The Director of Nursing/designee will re-educate the licensed staff on or before 3/21/2025 on the facility policy and revised procedure, "Drug Regimen Review," emphasizing timely completion and filing in the resident's medical record. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist completes medication regimen reviews monthly and provides a list of recommendations to the Director of Nursing. Recommendations from the prior month that remain outstanding are escalated in the report to the Director of Nursing for immediate completion. The Director of Nursing will monitor the completion of the MRR from the date of delivery until the recommendations are completed, including verification of required documentation. The Consultant Pharmacist will report trends identified in timely completion and filing of the MRRs to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement and to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F757 Drug Regimen is free from Unnecessary Drugs. CFR(s): 483.45(d)(1)-(6) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents receiving PRN medication without a duration, for a temporary condition such as a cough, are potentially affected by the facility practice. The Director of Medical Records generated an audit of all residents receiving guaifenesin oral liquid to identify residents whose medication does not have a stop date and are potentially affected by the facility practice. A copy of the audit was provided to the Director of Nursing on 2/27/2025 for further review and analysis.
Failure to Implement GDR and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to perform gradual dose reductions (GDR) for psychotropic medications in two residents. Despite recommendations from the consultant pharmacist and agreement from the psychiatric nurse practitioner (NP), the facility did not implement the changes in medication dosages for these residents. This oversight resulted in the residents continuing to receive higher doses of medications than necessary, increasing the risk of adverse effects. The facility also did not limit the duration of PRN lorazepam for a resident to 14 days or document a longer duration with a clinical rationale. This failure to adhere to the recommended duration for PRN medications increased the risk of the resident receiving the medication when it was no longer clinically appropriate, potentially leading to adverse effects. Additionally, the facility did not ensure that an antipsychotic medication was used for a clear indication or diagnosed condition for another resident. The facility also failed to monitor and document target behaviors related to the use of this medication. Furthermore, the facility allowed the simultaneous use of two antidepressants without clinical justification for a resident, increasing the risk of adverse effects.
Plan Of Correction
The Director of Nursing/designee audited the physician orders for psychotropic medications of all residents to identify residents who may be potentially affected by the facility practice on 3/6/2025. Thirty-five residents with psychotherapeutic medication therapy were audited. Five of 35 residents required the licensed nurse to clarify the physician's order with resident-specific targeted behaviors, stop date, duplicate medication therapy, and monitoring of targeted behaviors. The Director of Social Services/designee audited resident records who receive psychotherapeutic medications on 3/6/2025 to identify residents who do not have documented evidence of a gradual dose reduction in the medical record. Thirty-five residents receiving psychotherapeutic medications were audited. Two of 35 residents required a gradual dose reduction. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The IDT will review and revise the care plans of all residents with psychotherapeutic medication therapy to ensure care plans include resident-specific targeted behaviors and justification for dual medication therapy when indicated on 3/6/2025. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development will monitor the completion of staff training during new hire orientation, and as needed, on the facility's unnecessary medication policy and procedure. The Pharmacy Consultant shall monitor the medication regimen of residents each month to identify the potential for unnecessary drug use and report the results to the Director of Nursing and QAA quarterly. The Director of Social Services will monitor the Medical Records verification of complete physician orders, track gradual dose reduction attempts, and identify opportunities for GDR, and clearly defined diagnosis for use. Variance to standard concerns identified will be reported to the Director of Nursing. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.
Failure to Rotate Injection Sites and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin and anticoagulants. For three residents, the facility did not rotate the subcutaneous injection sites for insulin and heparin as required by physician orders and professional standards. This failure to rotate injection sites was observed in the administration records and confirmed by interviews with nursing staff, including Licensed Vocational Nurses and the Director of Nursing. The lack of rotation could lead to adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis. Resident 65, who has type 2 diabetes and requires insulin, had multiple instances where insulin was administered in the same area of the abdomen without rotation. Similarly, Resident 29, who is on DVT prophylaxis with heparin and insulin for diabetes, also had repeated injections in the same abdominal area. Resident 52, who has type 2 diabetes and cognitive impairments, received insulin injections in the same site without rotation. These practices were identified as medication errors by the nursing staff and the Director of Nursing, as they did not adhere to the physician's orders or the manufacturer's guidelines. Additionally, the facility failed to administer three doses of levothyroxine as ordered for Resident 197, who has hypothyroidism. The resident reported not receiving the medication consistently, and a review of the medication administration records confirmed that doses were missed. The Director of Nursing acknowledged that this was a medication error and emphasized the importance of administering medications as ordered to manage the resident's condition effectively.
Plan Of Correction
F760 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Licensed Nurses are rotating injection sites for Resident 65, 29, and 52 and all residents who receive routine injections. 1. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. 2. MD was notified about the missed doses on 2/28/25 with no new orders. 3. Licensed nurses are administering Resident 197's Levothyroxine in accordance with physician order. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents receiving routine injections in the same injection sites and who are not administered medications per physician order are potentially affected. The Director of Nurses/designee audited residents who receive routine injections from 2/15/2025 through 2/25/2025 to identify other residents who may be affected by the facility practice. The Director of Nurses/designee audited residents who receive Levothyroxine on 3/21/2025 to identify residents who did not receive the medication. A total of 19 residents receive Levothyroxine. 19 of 19 resident records accurately reflect doses remaining, indicating residents received their medication. Resident injection sites were rotated; and no other residents were identified as affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur; The Director of Staff Development/designee will re-educate the licensed nurses regarding the facility policy and procedure, "Diabetes Management," with emphasis on rotation of injection sites to avoid tissue damage from repeated injections on or before 3/21/2025. The DSD/designee will complete weekly audits of residents receiving subcutaneous injections to ensure licensed nurses are rotating injection sites routinely to ensure residents do not experience tissue damage to the extent possible. The DSD/designee will run an injection administration audit through PCC weekly to audit. Concerns identified will be reported to the Director of Nursing for further review, analysis, and follow-up. The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly for the purpose of process improvement. The Director of Nursing will monitor the DSD audits of resident subcutaneous injection sites by licensed nurses to ensure sites are rotated to mitigate tissue damage to the extent possible and to identify continued compliance or the need for further education or progressive disciplinary action. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during acceptable timeframes for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. Trends identified in the injection site rotation audits will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date 3/25/2025
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Two dented cans were found stored with non-dented cans, which the Dietary Manager (DM) confirmed should have been separated to prevent potential cross-contamination. The DM acknowledged that the dented cans were missed during the daily inspection by kitchen staff, emphasizing the importance of separating them to avoid using compromised cans that could release harmful chemicals. Additionally, an opened bag of crushed graham crackers was found without a date label indicating when it was opened. The DM confirmed that all opened items in the kitchen should be labeled with the date they were opened to ensure they are used within the recommended shelf life. The lack of labeling on the graham crackers meant staff could not determine if the product was beyond its recommended shelf life of one month, as per the facility's product shelf-life guide. These deficiencies had the potential to result in harmful bacterial growth and cross-contamination, posing a risk of foodborne illness to 128 of 150 medically compromised residents.
Plan Of Correction
Residents as a dented can may have a broken seal and can release chemicals which can cause cross-contamination on or before 3/19/2025. Food products must be dated when opened to assure staff knows when to discard the product. The Registered Dietitian will complete a kitchen sanitation audit, at a minimum of quarterly, to identify sanitation concerns including but not limited to presence of dented cans and opened, undated food products. A copy of the audit will be provided to the administrator and Dietary Manager for review and correction. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Dietary Manager/designee will monitor food storage, including the presence of dented cans and opened food products, to ensure the open date is documented on the product weekly. The Dietary Manager/designee will report trends identified in the RD and DM audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. --- F 812 F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The Infection Prevention Nurse re-educated Certified Nurse Assistant 2 regarding the facility policy and procedure Oxygen Therapy, with emphasis on placing resident oxygen tubing in a bag and discarding tubing that has been on the floor to reduce the potential for respiratory infection on 2/25/25. Resident 101's oxygen tubing was discarded and new tubing was labeled, dated, and replaced on 2/25/2025 at the time of observation during the survey. 2. The Infection Prevention Nurse re-educated CNA 1 on the facility policy "Hand Hygiene," with emphasis on performing handwashing prior to and following providing ADL care to residents and grooming assistance; and on the facility policy and procedure Enhanced Barrier Precautions, with emphasis on donning required PPE prior to providing close contact assistance for residents who have this precaution on 2/25/2025. 3. The DSD completed a Hand Hygiene competency with CNA 1 to ensure CNA 1 has the
Failure to Ensure Informed Consent for Psychoactive Medication
Penalty
Summary
The licensed nursing staff at the facility failed to ensure that a resident and/or their responsible party were fully informed about the risks and benefits of a psychoactive medication, specifically Zoloft, which is used to treat mental and mood disorders. The deficiency was identified for a resident who was admitted with diagnoses including major depressive disorder and acute respiratory failure with hypoxia. The resident's Minimum Data Set indicated intact cognition and the ability to make self-understood decisions. However, the Psychotherapeutic Medication Informed Consent Form for Zoloft did not specify the dosage, nor were the consent boxes checked to confirm the resident's agreement to take the medication. Interviews with the Registered Nurse and the Director of Nursing confirmed the omission of the dosage and unchecked consent boxes on the informed consent form. The facility's policy on informed consent, last reviewed in December 2024, requires that all material information be provided to residents to make informed decisions about their treatment, including the administration of psychotherapeutic drugs. The failure to include the dosage and obtain explicit consent violated the resident's right to make an informed decision regarding their medication.
Plan Of Correction
F552 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 34's physician provided informed consent for the use of Zoloft, including the strength of medication and Resident 34's acceptance or refusal of recommended psychotherapeutic medications on 02/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents using psychotropic medications without complete physician informed consent, including the dosage and the resident's choice to accept or refuse recommended medications, are potentially affected by the facility practice. The Director of Medical Records/designee audited the physician orders for residents who receive psychotherapeutic medications to verify the presence of a completed informed consent in the medical record and to identify residents who may potentially be affected by the facility practice on 3/20/2025. A total of 39 records were reviewed, and 0 records were identified with incomplete informed consents. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate licensed nurses and social services employees on the facility's Informed Consent policy with emphasis on verifying informed consent for the use of psychotropic medications on or before 03/20/2025. The DSD orients applicable new employees upon hire, annually, and as needed on the facility's Informed Consent policy and procedure, including verifying informed consents are complete with the dosage of medication and the resident's choice for the use of recommended psychotherapeutic medications. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify informed consent has been provided by the physician monthly, including documentation of the dosage and resident's choice, and provide physician orders for residents who receive psychotherapeutic medications to verify the presence of a completed informed consent in the medical record and to identify residents who may potentially be affected by the facility practice on 3/20/2025. A total of 39 records were reviewed, and 0 records were identified with incomplete informed consents. The measures to prevent recurrence include re-education of licensed nurses and social services employees on the facility's Informed Consent policy, orientation for new employees, monthly audits by the Director of Medical Records, and ongoing monitoring by the Director of Social Services. The Director of Staff Development will re-educate staff on or before 03/20/2025, and the Director of Medical Records will continue monthly audits, providing completed audits to the Director of Nursing for tracking and trending analysis. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have completed verified informed consent. D. How the facility plans to monitor its performance to make sure solutions are sustained: The IDT will review physician order changes four days weekly in the morning clinical meeting to ensure residents with orders for psychotherapeutic medications have evidence of a verified complete informed consent in the record. The Director of Staff Development will monitor the completion of staff training during new hire orientation and as needed on the facility's Informed Consent procedures, including verification of complete informed consent for the use of psychotropic medications. The Pharmacy Consultant shall monitor the medication regimen of residents each month to identify unnecessary medications and report the results to the Director of Nursing and QAA quarterly. The Director of Social Services will monitor the Medical Records verification of informed consent audit to identify variance to standard concerns and maintain compliance with this plan of correction. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 03/25/2025.
Failure to Maintain Homelike Environment Due to Damaged Equipment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, as observed during a random inspection. Resident 83, who was admitted with Parkinson's disease and other conditions, was found to have a landing mat with a torn portion in their room. This mat was intended to minimize injury due to the resident's high risk for falls, as indicated in their care plan and physician's orders. Despite the visible disrepair, staff did not notify the maintenance department to replace the mat, which compromised the resident's environment. Similarly, Resident 42, admitted with a diagnosis of malignant neoplasm and other conditions, also had a landing mat in disrepair. The mat, which was part of the resident's fall prevention strategy, had a portion ripped off. Staff, including a treatment nurse, confirmed the mat's condition but failed to report it to the maintenance department for replacement. This oversight resulted in the resident not having a homelike environment as required by the facility's policy. Interviews with the Director of Nursing and other staff confirmed that the damaged mats should have been reported and replaced to maintain a homelike environment. The facility's policy emphasizes the importance of a personalized and homelike environment, which was not upheld in these cases. The failure to address the disrepair of essential equipment like landing mats potentially affected the residents' quality of life, as the facility serves as their temporary home during recovery.
Plan Of Correction
F584 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Maintenance Director/designee removed Resident 83 and 42 floor mats on 2/27/2025. Resident 42 and Resident 83 were provided new floor mats on 2/27/2025. The IDT reviewed and revised Resident 83 and Resident 42 with their current interventions. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: The Nurse Supervisor/designee completed a room audit of all residents on 3/18/2025 to identify residents who may have floor mats in disrepair. No additional residents were identified with floor mats in disrepair. No other residents were affected by the facility's current practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate nursing staff on the facility policy Homelike Environment with emphasis on floor mats being in good condition without rips or tears. Re-education will be completed on or before 3/21/2025. The Central Supply Clerk will utilize the device consent audit and special needs/precautions list to ensure all devices and safety precautions are compliant. The Interdisciplinary Team will evaluate residents for the use of floor mats during their comprehensive audits and as needed. Floor mats for resident use will be inspected by the Director of Maintenance prior to being placed in a resident's room. D. How the facility plans to monitor its performance to make sure solutions are sustained: The DSD/Central Supply staff will monitor the floor mats in residents' rooms weekly to ensure they are in good repair without tears or rips. Floor mats identified in disrepair, including tears in the covering, will be removed immediately at the time of observation and replaced with a floor mat in good repair. No other residents were affected by the facility's current practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate nursing staff on the facility policy Homelike Environment with emphasis on floor mats being in good condition without rips or tears. Re-education will be completed on or before 3/21/2025. The Central Supply Clerk will utilize the device consent audit and special needs/precautions list to ensure all devices and safety precautions are compliant. The Interdisciplinary Team will evaluate residents for the use of floor mats during their comprehensive audits and as needed. Floor mats for resident use will be inspected by the Director of Maintenance prior to being placed in a resident's room. D. How the facility plans to monitor its performance to make sure solutions are sustained: The DSD/Central Supply staff will monitor the floor mats in residents' rooms weekly to ensure they are in good repair without tears or rips. Floor mats identified in disrepair, including tears in the covering, will be removed immediately at the time of observation and replaced with a floor mat in good repair. The Director of Staff Development will monitor the completion of staff training during new hire orientation, annually, and as needed on the facility's homelike environment practices, including equipment being in good repair. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 The Director of Staff Development will monitor the completion of staff training during new hire orientation, annually, and as needed on the facility's homelike environment practices, including equipment being in good repair. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 584 F604 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The pad alarm in Resident 303's room was removed on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents using pad alarms in the absence of device/restraint assessment, physician order, and care plan are potentially affected by the facility practice. The DSD/designee completed a room audit of all residents on 2/27/2025 to identify residents who may have pad alarms to verify the presence of a physical device/restraint assessment, physician order, informed consent, and care plan. A total of 149 records were reviewed. Two records were identified without a physician order, informed consent, care plan, or device/restraint assessment present in the medical record. The list of residents with pad alarms identified without a device/restraint assessment, physician order, informed consent, or care plan was provided to the DON for correction on 02/27/2025.
Failure to Obtain Proper Authorization for Bed Pad Alarm Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and documentation. Specifically, the facility did not obtain a physician's order, informed consent, or conduct a device use or restraint assessment for the use of a bed pad alarm for a resident. The resident, who had been admitted with diagnoses including end-stage renal disease and generalized muscle weakness, was observed with a bed alarm in place without the necessary documentation and assessments. The resident's medical records, including the Minimum Data Set, indicated that the resident had intact cognition and the ability to make medical decisions. Despite this, the facility did not have a care plan that included the use of the bed pad alarm as an intervention for fall risk, even though the resident was identified as high risk for falls. Observations confirmed the presence of the bed alarm, and interviews with staff revealed a lack of awareness regarding the necessary physician's order and informed consent. The Director of Nursing and Assistant Director of Nursing acknowledged the oversight, confirming that the required assessments, orders, and consents were not completed prior to the use of the bed pad alarm. The facility's policies on informed consent and physical restraints were not followed, which require a physician's order, informed consent, and a care plan for the use of any physical restraint. This deficiency placed the resident at risk for restricted freedom of movement and other potential harms.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Staff Development will re-educate licensed nurses and the IDT on the facility's Physical Restraints policy with emphasis on verifying informed consent, obtaining a physician order, developing a care plan and completing a device/restraint assessment for the use of devices having the potential to become an unnecessary restraint on or before, 3/20/2025. The DSD orients new employees upon hire, annually, and as needed on the facility's Restraint policy and procedure including verifying informed consent, care planning, physician order and assessments for use of devices. The Director of Medical Records will audit the orders of residents' devices to ensure there is documented verification informed consent, care planning, device/restraint assessment and physician order are present in the record. Results of the audit will be provided by the physician; and provide completed audits to the Director of Nursing for tracking and trending analysis and further follow through as needed. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development will monitor the completion of staff training during new hire orientation, and as needed on the facility's devices and restraints procedures, including verification of informed consent, care planning, physician order and assessment for use of bed/pad alarms. The Director of Nurses will monitor the Medical Records device and restraint audit to ensure all required components have been completed to identify variance to standard concerns and maintain compliance with this plan of correction. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 604 F 604 F640 Accuracy of Assessments CFR(s): 483.20(g) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 126's discharge assessment was transmitted 2/25/2025 and accepted into the QIES system on 2/25/2025. The Nurse Consultant/designee re-educated the MDS Nurse re: Transmitting Resident Assessments Timely on 3/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; The MDS Nurse completed an audit of resident discharge assessments 1/1/2025 through 3/01/2025 to ensure resident discharge assessments were completed and submitted as required by the RAI. All other resident discharge assessment locations were coded accurately. No other residents were identified as affected by the facility practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS
Failure to Include Dementia Diagnosis and Antipsychotic Use in Baseline Care Plan
Penalty
Summary
The facility failed to include a diagnosis of dementia and the use of the antipsychotic medication quetiapine on the baseline care plan for a resident upon admission. This oversight was identified during a review of the resident's admission records and baseline care plans. The resident was admitted with a diagnosis of dementia and was prescribed quetiapine for adjunct treatment of depression manifested by physical aggression. However, these critical details were not reflected in the baseline care plan, which is intended to provide initial instructions for resident-centered care. During an interview, the Director of Nursing acknowledged the importance of including a dementia diagnosis in the baseline care plan to address specific behaviors and challenges. The omission increased the risk that the resident's needs related to dementia might not be optimally addressed, potentially leading to a decline in their well-being. Additionally, the failure to document the use of quetiapine in the care plan increased the risk of adverse effects from antipsychotic therapy, particularly in residents with dementia.
Plan Of Correction
The comprehensive care plan may be developed instead of the baseline care plan for diagnoses such as dementia and the use of psychotherapeutic medications within 48 hours of the resident's admission. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development provides education regarding the baseline care plan, including pertinent diagnoses which may affect the residents' psycho-social well-being and use of psychotherapeutic medications during new employee orientation, annually, and as indicated when a variance to performance is identified. The MDS Nurse completes verification of the resident's comprehensive plan of care no later than 21 days following admission and evaluates the completion of the baseline care plan to identify any process concerns. The MDS Nurse will report significant trends to the DON for further review, analysis, and correction. The DON/designee will report significant trends identified in the MDSN and IDT audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or for the purpose of terminating this plan of correction when substantial compliance has been achieved. Allegation of Compliance Date: 3/25/2025. F 655 Not Specified F656 Develop/Implement Comprehensive Care Plan. CFR(s): 483.21(b)(1)(3) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 73 no longer uses Cephalexin, Ciclopirox, and Lotrimin cream. The interdisciplinary team developed and implemented a comprehensive person-centered care plan on 2/26/2025 for: 1. Resident 29's use of continuous positive airway pressure machine. 2. Resident 29's use of Humulin R insulin. 3. Resident 52's use of Insulin NPH. 4. Resident 97's preference for female caregivers. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents who use CPAP machines, Insulin to treat diabetes, and residents with preferences for a specified gender of caregiver are potentially at risk. The MDS nurse/designee ran a report of residents with diabetes; The Director of Medical Records ran a report of residents who use CPAP machines on 3/20/2025.
Failure to Review and Revise Care Plan for Resident with Physical Restraints
Penalty
Summary
The facility failed to ensure the interdisciplinary team (IDT) reviewed and revised the comprehensive care plan for a resident with multiple physical restraints. The care plan for the resident, who was admitted with conditions such as spondylosis, osteoarthritis, and anxiety disorder, was last revised on 8/19/2024. Despite the resident's dependency on mobility and activities of daily living, and the presence of fall precautions, the care plan was not reviewed quarterly as required. The resident's care plan included the use of bilateral bed bolsters, a floor mattress, a pad alarm in bed, a self-release belt while in a wheelchair, and an abdominal binder for safety. However, the care plan had not been updated since 8/19/2024, and there was no interdisciplinary meeting conducted to review and revise the care plan for the last quarter of 2024. This oversight was confirmed during interviews with the registered nurse and the Minimum Data Set Nurse, who acknowledged the importance of regular reviews to minimize the use of restraints and prevent complications. The facility's policy on physical restraints, last reviewed on 12/3/2024, emphasized that restraints should not be used for discipline or convenience and should be re-evaluated regularly. The Director of Nursing confirmed that the care plan should have been reviewed quarterly to assess the effectiveness of the interventions and goals. The failure to conduct these reviews had the potential for unnecessary use of physical restraints, which could lead to physical and psychosocial decline in the resident.
Plan Of Correction
F657 CFR(s): 483.21(b)(3)(i) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The IDT met on 2/24/25 to review resident 73's use of physical restraints, to review and revise the care plan to reduce the potential for unnecessary use of physical restraint. Evaluated all devices and family notified and wants the devices to continue due to benefits outweighing the risks. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: All residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur: The MDSN/designee will re-educate the nursing staff and IDT on completing a physical restraint/device assessment quarterly and with significant change; with revision of the care plan immediately following to reduce the potential for unnecessary use of physical restraint that can result in physical and psychosocial decline of the resident. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Restraints," including completion of a quarterly restraint/device assessment with revision to the resident's care plan immediately following or as soon as practicable to support the residents' psycho-social well-being. The Director of Nursing/designee will re-educate the licensed nurses and interdisciplinary team on or before 3/21/2025 regarding the facility policy and procedure, "Care Plan," timing and revision with emphasis on completion of revised care plan interventions after each assessment including comprehensive and quarterly assessments or at the time of a significant change. D. How the facility plans to monitor its performance to make sure solutions are sustained: The IDT will monitor completion of quarterly and with significant change assessments, with revision of the care plan immediately following to reduce the potential for unnecessary use of physical restraint that can result in physical and psychosocial decline of the resident. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Restraints," including completion of a quarterly restraint/device assessment with revision to the resident's care plan immediately following or as soon as practicable to support the residents' psycho-social well-being. The Director of Nursing/designee will re-educate the licensed nurses and interdisciplinary team on or before 3/21/2025 regarding the facility policy and procedure, "Care Plan," timing and revision with emphasis on completion of revised care plan interventions after each assessment including comprehensive and quarterly assessments or at the time of a significant change. D. How the facility plans to monitor its performance to make sure solutions are sustained: The IDT will monitor completion of the resident's care plan following completion of the resident's quarterly assessments in accordance with the RAI schedule to reduce the potential for the use of unnecessary restraints. The Director of Nursing will report trends identified during the IDT meetings and care plan review to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F657 F657 F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. 2. MD was notified about the missed doses on 2/28/25 with no new orders. 3. The treatment nurse completed a skin assessment of Residents 69, 29, and 52 to identify signs or symptoms of skin breakdown in the area of routine injections. Residents 69, 29, and 52 did not have any signs or symptoms including discomfort in the area of injection sites. 4. Licensed Nurses are rotating injection sites for Resident 69, 29, and 52 and all residents who receive routine injections. 5. Licensed nurses are administering levothyroxine to Resident 197 in accordance with the physician order for administration. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken:
Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for a resident, identified as Resident 65, who required assistance with activities of daily living (ADLs). The deficiency was observed during an inspection where a Certified Nursing Assistant (CNA) did not follow the proper procedure for perineal care. The CNA did not perform hand hygiene before putting on gloves, used washcloths that were not properly sanitized, and did not follow the facility's policy and procedure for perineal care. Resident 65, who had been admitted to the facility with diagnoses including type 2 diabetes mellitus and generalized muscle weakness, required substantial assistance with ADLs due to moderately impaired cognition. The resident's care plan indicated the need for assistance with personal hygiene and toileting every shift. However, during an observation, the CNA failed to clean the overbed table before placing washcloths, did not use separate basins for soapy and rinse water, and did not ensure the washcloths were at a comfortable temperature for the resident. Interviews with the CNA and the Director of Staff Development confirmed that the CNA did not adhere to the facility's procedures for perineal care, which included washing hands, using clean washcloths for each stroke, and ensuring the resident's comfort. The Director of Nursing also confirmed that the failure to follow these procedures could affect the resident's dignity, quality of life, and increase the risk of infection.
Plan Of Correction
Glove use, sanitizing the overbed table before and after use, and not exiting the resident's room with gloves on 3/20/25. The DSD orients all nursing employees at the time of hire, annually, and as needed regarding the facility's Activities of Daily Living responsibilities, including providing grooming care with hand washing, proper glove use, and removing gloves prior to exiting the residents' rooms. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Director of Staff Development will randomly assess certified nurse aide grooming skills through the day when on shift to ensure grooming assistance is provided in a manner that supports the resident's psychosocial well-being. The Infection Prevention will monitor certified nurse aides' infection control practices, including donning and doffing gloves when required, removing gloves prior to exiting a resident's room following care, and cleaning and sanitizing overbed tables when used. The Director of Activities will ask residents if there are any concerns related to nursing care during the resident council meeting to identify any non-compliance with grooming. The Director of Staff Development/designee will report significant trends identified with resident grooming concerns, hand washing, and cleaning and sanitizing overbed tables during use for cares to the resident altercations to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F684 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: The Director of Nursing audited residents who receive Levothyroxine on 3/21/2025 to identify residents who did not receive the medication.
Failure to Administer Thyroid Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was admitted with diagnoses including hypothyroidism, did not receive three doses of levothyroxine as ordered. The resident's care plan required daily thyroid replacement therapy, but the Medication Administration Record indicated that only 10 out of 15 doses were administered over a specified period. The Licensed Vocational Nurse (LVN) acknowledged the missed doses and did not complete a change in condition or progress note regarding the missed medication. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the missed doses until later, and the facility's policy required notifying the resident's physician and responsible party of any medication errors. The LVN did not inform the DON or initiate a change in condition assessment, which was necessary to monitor the resident for any adverse consequences. The facility's policy on medication errors emphasized the importance of notifying the physician and monitoring the resident according to the physician's instructions.
Plan Of Correction
A total of 19 residents receive Levothyroxine. Nineteen of 19 resident records accurately reflect doses remaining, indicating residents received their medication. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly, for the purpose of process improvement. The Director of Nursing will monitor the Director of Medical Record audits of resident medication, Levothyroxine, to ensure residents receive their medication in accordance with physician orders. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during an acceptable timeframe for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. If the DON identifies residents who did not receive their Levothyroxine in accordance with physician orders, the DON will begin an investigation into the medication error as applicable and identify the root cause of the variance to the physician order to re-educate or discipline as determined. The facility plans to monitor its performance to ensure solutions are sustained through ongoing oversight and reporting. Trends identified in the administration of Levothyroxine and other medications will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F689 Free of Accident Hazards Supervision/Devices CFR(s): 483.25(d)(1)(2) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The licensed nurse removed two tubes of triamcinolone acetonide from Resident 41's bedside table on 2/24/2025. 2. Resident 348's floor pad alarm was activated by a certified nurse assistant on 2/28/2025. 3. Housekeeping cleaned the spill and placed a wet floor sign in the area of nine residents when fluids were identified on the floor on 2/25/2025, to reduce the potential to result in falls resulting in injuries like fractures. 4. Furniture in the rooms of Residents 34, 83, and 42 were removed from the floor pad mat to reduce the risk of injury from a fall on 2/28/2025. 5. The IDT completed a fall assessment for Resident 83 and reviewed and revised the 2/24/25 care plan for injuries related to falling.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to a potential risk of urinary tract infections (UTIs) for two residents. Resident 83, who was admitted with diagnoses including Parkinson's disease and neurogenic bladder, was observed with a urinary catheter tubing that had a loop, which was confirmed by an LVN. The loop in the tubing contained urine, which could prevent urine from flowing freely and potentially cause a UTI. The Director of Nursing (DON) confirmed that catheter tubing should be positioned properly to prevent loops or kinks, as these can lead to urine backing up into the bladder. Similarly, Resident 53, who had severe cognitive impairment and required total assistance with activities of daily living, was also observed with a loop in the urinary catheter tubing. This was confirmed by another LVN, who stated that the loop could cause urine to back up into the bladder, increasing the risk of a UTI. The DON reiterated the importance of ensuring that catheter tubing is free from loops or kinks to maintain unobstructed urine flow. The facility's policy and procedure on indwelling catheter use, as well as clinical guidelines for preventing catheter-associated UTIs, emphasize the need to maintain unobstructed urine flow and keep catheter tubing free from kinks. However, the observations and interviews indicate that these guidelines were not followed, resulting in a deficiency in the care provided to residents with urinary catheters.
Plan Of Correction
B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents using indwelling catheters that have kinks or loops in their tubing are potentially affected. The Director of Nursing audited all residents who have an indwelling catheter on 2/26/2025 to identify residents whose drainage tubes are kinked or looped, in order to identify other residents who may be affected by the facility practice. No other residents' catheter drainage tubing was kinked or looped. No other residents were identified as affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Nursing/designee will re-educate the licensed nurses on or before March 21, 2025, regarding the facility policy and procedures "Indwelling Urinary Catheters," with emphasis on ensuring proper placement of the urinary drainage tubing to prevent kinks or loops, thereby decreasing the potential for urine backflow and the development of urinary tract infections. The Interdisciplinary Team (IDT) will review physician orders received since the prior business day each day during the daily clinical meeting held five times weekly. This review aims to identify residents admitted with urinary drainage catheters to ensure interventions are in place to prevent tubing from being kinked or looped, reducing the potential for urinary tract infections, and to ensure these interventions are documented on the care plan. The IDT will review the care plans of all residents with indwelling urinary catheters to ensure they receive the necessary care and services to reduce the potential for recurrent urinary tract infections, including proper placement of the urinary drainage tubing, on or before 3/13/2025. No other residents' catheter drainage tubing was kinked or looped. No other residents were identified as affected by the facility practice. The Director of Nursing/designee will re-educate the licensed nurses on or before March 21, 2025, regarding the facility policy and procedures "Indwelling Urinary Catheters," with emphasis on ensuring proper placement of the urinary drainage tubing to prevent kinks or loops, thereby decreasing the potential for urine backflow and the development of urinary tract infections. The IDT will review physician orders received since the prior business day each day during the daily clinical meeting held five times weekly. This review aims to identify residents admitted with urinary drainage catheters to ensure interventions are in place to prevent tubing from being kinked or looped, reducing the potential for urinary tract infections, and to ensure these interventions are documented on the care plan. The IDT will review the care plans of all residents with indwelling urinary catheters to ensure they receive the necessary care and services to reduce the potential for recurrent urinary tract infections, including proper placement of the urinary drainage tubing, on or before 3/13/2025. The Director of Staff Development/designee will continue to provide indwelling urinary catheter care training to nursing employees upon hire, annually, and as needed as part of the facility’s training and education program. The Director of Staff Development orients newly hired staff on the facility policy and procedure for indwelling urinary catheters. The DSD will provide skill competency verification to the certified nursing assistants (CNAs) at the time of hire for the placement of urinary catheter drainage tubing to ensure CNAs have the necessary skills to reduce the potential for UTIs by ensuring the urinary drainage tubing is not kinked or looped. Employees identified with variance to the standard of practice; and this plan of correction, will be re-educated with skill evaluation at the time of identification. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Infection Prevention Nurse will monitor residents with indwelling catheters at the time of admission or when a new catheter is placed to ensure person-centered interventions to reduce the risk for recurrent urinary tract infections are present on the care plan and that the nursing staff places the urinary drainage tubing properly to ensure kinks or loops are not present in the tubing. The charge nurse will monitor residents with indwelling urinary catheters to ensure drainage is properly placed, to reduce the risk of urinary tract infections to the extent possible. The Infection Prevention Nurse/designee will report trends identified in kinked or looped urinary drainage tubing to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025
Failure to Address Resident's Pain During ADL Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 65, during the provision of activities of daily living (ADLs) care. The incident involved a Certified Nursing Assistant (CNA 1) who did not recognize and address the resident's verbalization of pain while assisting with putting on socks. Despite Resident 65 expressing significant pain and requesting not to be touched, CNA 1 continued with the task, which led to the resident screaming and pulling away. CNA 1 acknowledged that the correct procedure would have been to stop the care and notify the Charge Nurse (CN) to administer pain medication. Resident 65 had a history of type 2 diabetes mellitus, long-term insulin use, and generalized muscle weakness. The resident was admitted to the facility with moderately impaired cognition and required assistance with various ADLs. The resident's care plan included specific interventions for pain management, such as administering pain medication as ordered and responding immediately to any complaints of pain. However, these interventions were not followed during the incident, as CNA 1 did not stop the care or notify the CN promptly. Interviews with the Licensed Vocational Nurse (LVN 9) and the Director of Nursing (DON) confirmed that the facility's protocol required CNAs to stop care and notify the CN when a resident verbalizes pain. The facility's policy on pain management emphasized recognizing pain through verbal and nonverbal cues and addressing it promptly. The failure to adhere to these protocols resulted in the resident experiencing unnecessary pain and discomfort, potentially affecting their quality of life.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate the certified nursing assistants starting on 3/18/25 regarding the facility policy and procedures "Pain Assessment and Management" requirements for CNAs to report residents' complaints of pain when a resident has: 1. Non-verbal pain indicators, as patient applicable, 2. Verbal report of pain on a 1-10 pain scale where 10 is the most severe level of pain. The DSD, as part of the facility's new employee orientation, will educate certified nursing assistants on the facility policy and procedure for reporting residents' complaints of pain or observations of non-verbal indicators of pain to the charge nurse for management of resident pain. The charge nurse will evaluate residents' pain level each shift and provide pain medication as indicated. Each resident will be evaluated for pain at the time of admission, quarterly, annually, and with an exacerbation as well as each shift to ensure residents receive adequate pain management to reduce the potential for residents to refuse care related to discomfort. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Director of Staff Development is responsible for monitoring certified nursing assistants' skill validation during new hire orientation, annually, and as needed when a variance to standard is identified in reporting a resident's verbal complaints of pain. Competency-related concerns identified by the DSD will be reported to the Director of Nursing for further review and instruction as indicated. The Director of Staff Development/designee will report significant trends identified in the DSD pain management skill reports to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or for the purpose of terminating this plan of correction when substantial compliance has been achieved. Allegation Of Compliance Date: 3/25/2025. --- F755 Pharmacy Services Procedures Pharmacist/Records CFR(s): 483.45 (a)(b) (1)-(3) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. LVN 4 signed Resident 87 Clonazepam ODT 0.5mg at 1:40 pm, reconciling the narcotic log and remaining Clonazepam for Resident 87 on 2/25/2025. LVN 3 signed Resident 93's Lorazepam 1mg at 1:07 pm, reconciling the narcotic log and remaining Lorazepam for Resident 93 on 2/25/2025. LVN 3 and LVN 4 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure Administering Medications with emphasis on the standard of practice pour, pass, chart to ensure medications including controlled substances are signed, reconciled on the narcotic log, and medication administration record when the medication is administered. 2. LVN 6 administered Resident 347's Alprazolam on 2/25/2025. LVN 6 and LVN 7 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure assessing and administering as-needed medications when residents
Failure to Discontinue PRN Medication as per Policy
Penalty
Summary
The facility failed to reevaluate or discontinue a PRN order for guaifenesin oral liquid for a resident after 10 days, as required by the facility's policy. The resident, who was admitted with diagnoses including anxiety disorder and had a history of worsening functional and cognitive decline, was prescribed guaifenesin to be taken every four hours as needed for congestion. However, the order did not specify a stop date, and the medication continued to be available beyond the 10-day limit set by the facility's policy. The consultant pharmacist had recommended that the facility indicate the length of therapy for the PRN guaifenesin, in line with the policy that limits cough and cold products to 10 days. Despite this recommendation, there was no apparent response from the facility. During an interview, the Director of Nursing acknowledged the failure to limit the use of the medication as per policy, which increased the risk of the resident receiving the medication when it was no longer clinically appropriate. This oversight could have led to adverse effects and a decline in the resident's quality of life.
Plan Of Correction
2 residents had orders for guaifenesin oral liquid as needed. 0 of 2 residents were identified without a duration for use. 1 of 2 residents' orders were clarified and/or discontinued by the licensed nurse on 3/18/25. No other residents were affected by this deficient practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Medical Records will audit the physician orders for PRN medications monthly to ensure all as needed medications have a duration for use and include a stop date as part of the order. The Director of Nursing/designee will re-educate the nursing staff on or before, 3/21/2025, re: the facility's policy, "Physician Telephone Orders," with emphasis on ensuring orders are complete and include a stop date for as needed medications. The DSD orients new employees upon hire, annually and as needed on completion of physician orders including completing the order to include stop dates for as needed medications to treat temporary conditions. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Medical Records will audit physician orders for as needed medications monthly to ensure orders contain a stop or discontinue date. As needed orders identified without discontinuation or stop dates will be provided to the Director of Nursing for further review and correction. The Director of Nursing will report significant trends identified during review of the medical records monthly audit to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; or for determination of substantial compliance and termination of this plan of correction. Substantial compliance will be demonstrated by three consecutive Quality Assurance reviews without variance to standard findings. Allegation of Compliance Date: 3/25/2025 F758 Free From Unnecessary Psychotropic Meds/PRN Use CFR(s): 483.45(c)(3)€(1)(5) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; 1. The IDT completed a gradual dose reduction assessment on Residents 1 and 71 on 2/28/2025. 2. The licensed nurse clarified Resident 101's use of Lorazepam PRN on 2/24/2025. 3. Resident 68's use of antipsychotic medication, Quetiapine, was discontinued on 1/29/25. 4. The licensed nurses are monitoring and documenting Resident 347's behaviors of "repetitive physical movements and restlessness" related to the use of PRN alprazolam. 5. Resident 347's simultaneous use of sertraline and escitalopram, both used to treat depression, was clarified by the licensed nurse on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents with psychotherapeutic medication therapy are potentially affected by the facility practice.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly provide dental services for a resident, identified as Resident 89, by not scheduling a dental appointment despite a physician's order for a dental consult. The resident was admitted to the facility with conditions including rheumatoid arthritis, osteoporosis, and generalized muscle weakness. The resident had requested routine dental care from the social services department approximately three months prior but did not receive a response or appointment. The resident's Minimum Data Set indicated intact cognition and required assistance with activities of daily living. Interviews with facility staff revealed that the dentist visits the facility one to two times a month, and residents are seen based on a list provided by the facility. The Social Services Assistant acknowledged that the resident's insurance denied authorization for in-facility dental services, and arrangements for an external appointment were not made. The Social Services Director confirmed the lack of documentation and communication regarding the resident's dental care needs. The facility's policy requires assisting residents in obtaining necessary dental services, including arranging appointments and transportation if needed, which was not adhered to in this case.
Plan Of Correction
F791 Routine/Emergency Dental Services in NFs CFR(s): 483.55(b)(1)-(5) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Director of Social Services arranged dental services for Resident 89, and she was examined by the dentist on 3/6/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with dental service needs are potentially affected by the facility practice. The Director of Social Services audited long-term resident records to identify residents who had not been seen by the dentist within the last 12 months on 3/24/25. A total of 47 resident records were reviewed. Three of 47 residents had not been evaluated during the prior 12 months by the dentist. These residents were interviewed to identify any emergent dental needs. No residents requested an emergency dental visit. The Director of Social Services placed residents who had not received an annual routine dental visit on the dentist list for evaluation on 3/28/2025. No other residents were affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Administrator re-educated the Director of Social Services regarding the facility policy and procedure, "Dental Services," emphasizing that resident requests for dental exams must be scheduled during the next routine dentist visit, as soon as possible if the dental need is emergent, on 3/24/2025. The Director of Social Services will create a log of all residents and their dental visits, including requests for additional services by the dentist when needed. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Director of Social Services will maintain a log of all residents and their dental visits, including requests for additional services by the dentist when needed. The Director of Social Services will use the log to monitor the exams and requests for further dental needs of the residents, including the date the exam is completed and any further follow-up needed. The Director of Social Services will report trends identified in the timely completion of dental visits for residents to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F806 Resident Allergies Preferences Substitutes CFR(s): 483.60(d)(4)(5)
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident 59, by serving fish, a food the resident dislikes, during lunch on February 28, 2025. This incident was observed during a concurrent observation and interview with the resident, who confirmed the presence of fish on their plate despite their known dislike for it. The resident's dietary profile, updated on January 29, 2025, clearly indicated a dislike for fish, and the meal ticket for that day also reflected this preference. However, the meal ticket was not adhered to, resulting in the resident being served fish. Interviews with the Dietary Supervisor and Certified Nursing Assistant (CNA) 6 revealed that the kitchen staff was aware of the resident's dietary preferences and intolerances, and the meal ticket system was in place to prevent such errors. Despite this, the oversight occurred, and the Dietary Supervisor acknowledged that multiple staff members failed to notice the error. The Director of Nursing expressed concern that serving a disliked food could lead to psychosocial issues and potential weight loss for the resident. The facility's policy emphasizes respecting residents' dietary choices and ensuring their nutritional needs are met, but this incident demonstrated a lapse in following these guidelines.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 59 is receiving his meals per his choices and preferences. The Dietary Services Supervisor completed a Food Preference Evaluation to identify Resident 59's food likes and dislikes to ensure Resident 59 is served meals according to his preference on 2/28/2025. The Dietary Service Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. The Dietary Services Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents not receiving meals per their preferences are potentially affected. The Social Service Director audited resident grievances from January 1 through February 28th, 2025, to identify grievances related to meal service on 3/17/2025. The Activities Director audited the last two months of Resident Council minutes to identify any grievances related to meal service on 3/17/2025. No other residents were identified as having concerns related to meal service and food preferences. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Supervisor completed dietary competency evaluations of the cooks and meal service staff on 3/13/2025 to ensure the cooks and meal service staff prepare the resident's meal tray per their documented meal ticket preferences. The Dietary Supervisor will implement the use of the CAHF Meal Accuracy Report once weekly to identify meal service accuracy concerns and report findings to the Quality Assurance Committee for improvement beginning December 2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Registered Dietitian will, as part of the routine kitchen audit, monitor meal service to ensure meals are prepared in accordance with the physician order and the cook has the appropriate skills and competency to prepare the resident meals. This will be done twice a month, and the RD will utilize the CAHF Food & Nutrition Meal Tray Accuracy - Quality Assurance Report. The IDT, including the RD, will monitor resident weight monthly to identify residents with unplanned weight loss and determine the root cause of the weight loss. The Director of Activities monitors the grievances of residents monthly during resident council and will report food-related concerns to the DSS following the resident council meeting for immediate correction. The Director of Social Services will monitor the grievance log for meal preparation concerns and report these concerns to the dietary services department for immediate correction. The Director of Nursing/designee will report trends identified in the dietary feedback audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F812 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The two dented cans in dry storage were removed and placed in the dented can area by the Dietary Manager on 2/24/2025 at the time of observations during the survey to avoid using them for residents, as the seal of the dented cans had already been broken and can release chemicals which can cause cross-contamination. 2. The Dietary Manager removed the box of open, undated graham cookie crumbs. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: 128 residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Services Director will re-educate the dietary staff on or before 3/19/2025 regarding the facility policy and procedures: Dented cans must be removed from the food supply and placed in the dented can area to avoid using them for residents.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) placed a nasal cannula (NC) that had fallen on the floor onto a resident's bed. The resident, who was dependent on supplemental oxygen due to Alzheimer's disease and other conditions, had a care plan indicating the need for oxygen therapy. The CNA's action of placing the NC on the bed after it had been on the floor was identified as an infection control issue by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), as it could lead to cross-contamination and potential infection. In the second incident, a CNA failed to perform hand hygiene and wear appropriate personal protective equipment (PPE) while providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP). The resident had a biliary drain, which required EBP to prevent infection. The CNA did not notice the EBP sign and proceeded to provide care without the necessary precautions, which was acknowledged by both the CNA and the LVN as a failure to adhere to infection control protocols. The Infection Preventionist and the DON confirmed that proper hand hygiene and PPE use were required to prevent the spread of infection. Both incidents highlight the facility's failure to adhere to its own policies and procedures regarding infection prevention and control. The facility's policies, which were last reviewed in December 2024, clearly outlined the need for proper handling of medical equipment and the use of PPE during high-contact activities. The deficiencies observed in these incidents had the potential to spread infections among residents and staff, as noted in the report.
Plan Of Correction
Necessary skills to complete the task prior to assisting residents with ADL care on 2/25/25. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with oxygen therapy and those on Enhanced Barrier Precautions are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Infection Prevention Nurse will re-educate the nursing staff on or before 3/21/2025 re: the facility policy, "Enhanced Barrier Precautions," emphasizing identifying the residents who have EBP and the use of required PPE during cares involving direct contact on or before; and the policy Oxygen Therapy with emphasis on proper storage and handling to reduce the potential for transmitting respiratory infection. The Infection Prevention Nurse/designee will in-service newly hired certified nurse assistants at the time of hire and all direct care staff annually and as needed on the facility procedure Oxygen Therapy emphasizing infection control standards and proper storage of the tubing and nasal cannula to reduce the potential for transmission of respiratory infection. The DSD will in-service newly hired certified nurse assistants, at the time of hire, annually and when a variance to standard is identified on the facility hand hygiene and as needed on the facility procedure Enhanced Barrier Precautions to reduce the risk of transmitting infections and increased health risk for residents. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Infection Prevention Nurse will conduct routine walking infection prevention rounds at least twice a week including monitoring staff for use of recommended PPE when providing care to residents with EBP and the placement and storage of oxygen tubing including nasal cannula to reduce the risk of transmitting infections and increasing health risks for residents. The Director of Nursing will monitor nursing staff performance or continued compliance with EBPS through observation, IPN reports and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in EBP procedures to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.
Late Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) Discharge Assessment for a resident, identified as Resident 126, within the required timeframe. Resident 126 was admitted to the facility with diagnoses including a fracture of the neck of the left femur, gout, and alcohol abuse. The resident was discharged home with home health care services, including physical and occupational therapy, as well as a home health aide. The MDS Discharge Assessment was supposed to be transmitted by 11/20/2024, but it was not submitted until 2/25/2025, which was considered late. Interviews with the Director of Nursing and MDS Nurses revealed that the delay in transmitting the MDS Discharge Assessment could potentially affect billing, resident assessment, and the facility's quality measures. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual require that the MDS be transmitted electronically no later than 14 calendar days after the MDS completion date. The failure to transmit the assessment in a timely manner was identified during a review of the Final Validation Report, which documented the late submission of Resident 126's MDS assessment.
Plan Of Correction
Support staff on the facility policy and procedure Resident Assessment Instrument, with emphasis on timely submission and discharge assessments on 3/24/25. D. How the facility plans to monitor its performance to make sure solutions are sustained; The MDS Consultant/designee will monitor timely completion and submission of Resident discharge assessments. Concerns identified will be reported to the Director of Nursing and MDS Nurse for immediate completion of modification assessment and submission to QIES. The Director of Nursing/designee will report trends identified in the MDS Consultant audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; and potential termination of this plan of correction when substantial compliance has been met. Substantial compliance shall be indicated at the discretion of the QAA Committee following three consecutive evaluations of MDS audit reports without findings of a variance to standard. Allegation of Compliance Date 3/25/2025. F 640 F 640 F 641 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The MDS added on 2/27/25 the diagnosis of Dementia to the list of active diagnoses. RT conducted an assessment on resident 29 for his CPAP on 2/26/2025. Resident 104's name was corrected in her MDS on 2/18/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; The Director of Nursing and Nurse Managers audited the MDS completion of Residents with diagnoses of dementia to ensure resident assessments were accurate and included a diagnosis of dementia under section I to identify other residents with diagnoses of dementia not accurately documented under section I on 3/17/2025. The DON and Nurse Managers audited a total of 30 resident MDS assessments. The MDS Nurse submitted a correction on 5 of 30 resident assessments requiring corrections to section I.
Inaccurate Resident Assessments Lead to Deficiencies in Care Planning
Penalty
Summary
The facility failed to ensure accurate assessments for residents, leading to deficiencies in care planning and treatment. For one resident, the Minimum Data Set (MDS) did not reflect a diagnosis of dementia, despite the resident being prescribed donepezil, a medication used to treat dementia. The MDS nurse acknowledged that the pre-admission paperwork did not include dementia as a diagnosis, and the physician should have been consulted to clarify the order. This oversight resulted in the absence of a resident-centered care plan for dementia, potentially affecting the resident's functional or psychosocial status. Another resident's assessment was inaccurate as the MDS did not indicate the use of a home continuous positive airway pressure (CPAP) machine, despite the resident having obstructive sleep apnea and using the CPAP at the facility. The MDS nurse admitted not seeing the CPAP during the assessment, and staff failed to report its presence, leading to the lack of an order and care plan for its use. This omission could delay necessary care and treatment for the resident. Additionally, the facility did not accurately code a resident's MDS to reflect their legal name as it appears on government-issued identification. This discrepancy was noted across multiple assessments, and the Director of Nursing emphasized the importance of entering the correct legal name to ensure accurate billing and service delivery. The facility's policy on accuracy of assessments was not adhered to, resulting in potential impacts on the resident's plan of care and delivery of necessary services.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS support staff on the facility policy and procedure Resident Assessment Instrument, with emphasis on accurate completion of the MDS including section I active diagnoses. The MDS nurse will work with the business office to obtain the residents' government issued ID/common working file in order to accurately reflect the residents' legal name. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Medical Records Director/designee will monitor MDS accuracy of section I and the residents' active diagnosis list for five records monthly for three months. The Medical Records Director/Designee will get the common working file/government ID of all patients to audit the accuracy of name once a month. Concerns identified will be reported to the Director of Nursing and MDS Nurse for immediate completion of modification assessment and submission to QIES. The Director of Nursing/designee will report trends identified in the Medical Records audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; and potential termination of this plan of correction when substantial compliance has been met. Substantial compliance shall be indicated at the discretion of the QAA Committee following three consecutive evaluations of MDS audit reports without findings of a variance to standard. Allegation of Compliance Date 3/25/2025. F 641 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 68's diagnosis of dementia was added to her comprehensive assessment and care plan on 1/29/25. Resident 68's antipsychotic was discontinued on 2/14/25. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; All residents have the potential to be affected by the facility practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS support staff on the facility policy and procedure Baseline Care Plan with emphasis on diagnosis and medication care planning on 3/24/25. The IDT will review the baseline care plan of newly admitted the following business day to ensure the plan includes the necessary information to care for the resident including diagnoses which may affect the resident's psychosocial well-being and psychotherapeutic medications which may affect the resident's quality of life.
Latest citations in California
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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