The Pavilion At Ocean Point
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 3202 Duke Street, San Diego, California 92110
- CMS Provider Number
- 055322
- Inspections on file
- 65
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Pavilion At Ocean Point during CMS and state inspections, most recent first.
A resident with a history of dysphasia after a stroke was inaccurately coded for malnutrition on the MDS by the MDS nurse without the required physician documentation. Although a query was provided for physician signature, it was not signed before the MDS was completed and submitted to CMS, resulting in inaccurate information being reported.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with severe cognitive impairment and high fall risk was left unattended in a wheelchair, resulting in a fall and injury. The care plan did not include individualized interventions appropriate for the resident's inability to use a call light or communicate needs, and staff resources did not provide specific fall prevention strategies.
A resident with severe cognitive impairment and high fall risk was left unsupervised in their room, despite being unable to use the call light or communicate needs. Usual fall prevention strategies included keeping the resident at the nurses station for monitoring, but on this occasion, the resident was alone and fell from a wheelchair, sustaining a head injury that required hospital assessment. Staff interviews confirmed that the interventions in place were not effective for this resident's specific needs.
A resident was subjected to undignified care when a CNA held a soiled wipe with bowel movement close to the resident's face during perineal care, after the resident questioned the cleaning process. The CNA admitted to this action, and facility leadership confirmed it was inappropriate and demeaning, violating policies that require staff to promote resident dignity and respect.
A resident in a shared room was unable to locate a TV remote control and did not receive assistance from staff, resulting in a physical altercation with another resident. The room had insufficient TV remote controls for the number of beds, and no work order was submitted to address the issue. Facility policy requires staff to accommodate residents' needs and preferences, but this was not followed, leading to the incident.
A resident was transferred from the SNF to a hospital and, after being medically cleared, was denied readmission to the SNF without receiving a timely written discharge notice or information about appeal rights. Facility administration confirmed there was no documentation of discharge notification or communication with responsible parties.
The facility failed to follow infection control practices by not consistently checking water temperatures or testing for pathogens, leaving a personal belonging on a clean bed intended for a new resident, and not performing hand hygiene between medication administrations. These actions were contrary to the facility's policies and placed residents at risk for infections.
A facility failed to obtain informed consent for psychotropic medications prescribed to a resident with schizoaffective disorder and major depressive disorder. The resident, under conservatorship and unable to make medical decisions, was prescribed clonazepam, valproic acid, and olanzapine without documented consent. Interviews and record reviews confirmed the absence of consents, contrary to the facility's policy requiring verification of informed consent by the licensed nurse.
A facility failed to ensure a POLST was signed by the Responsible Party for a resident with cognitive communication deficit, who lacked decision-making capacity. The POLST was signed by the physician but not by the resident's decision maker, as required by facility policy. Interviews with staff confirmed the oversight, highlighting a potential risk of not honoring the resident's end-of-life wishes.
A resident expressed concern about an unstable sink in her bathroom, which had a large hole in the wall beneath it. Despite being reported earlier, the issue was marked as resolved by maintenance staff, although the sink remained unsafe. The resident, who was cognitively intact and had mobility issues, felt uncomfortable with the condition, which was not addressed adequately by the facility.
A resident with cirrhosis of the liver was transferred to an acute care hospital without receiving a written notice of discharge. Two LNs involved in the discharge process admitted to not providing the notice, with one unfamiliar with the form. The DON acknowledged the oversight, which was against the facility's policy requiring a Notice of Proposed Transfer and Discharge document prior to discharge.
A resident with liver cirrhosis was transferred to a hospital without receiving a written notice of the bed-hold policy, as required by the facility's policy. Two LNs involved in the discharge confirmed the omission, and the DON acknowledged the oversight.
A facility failed to accurately document medication in the MDS for a resident, leading to potential errors in medical decisions. The MDS indicated insulin administration, but no orders were found in the resident's medical record. The MDS coordinator admitted to marking the MDS in error, contrary to the facility's policy on accurate resident assessments.
A resident with mental health diagnoses did not have a timely PASARR II completed due to a letter indicating inability to participate in the evaluation. Despite this, no follow-up was conducted, contrary to facility policy requiring the MDS Coordinator to ensure PASARR updates.
The facility failed to create care plans for psychotropic medications for two residents, potentially affecting communication among healthcare providers. One resident with Vascular Dementia and Major Depressive Disorder was on Seroquel without a care plan, while another with Major Depressive Disorder was on lorazepam and citalopram without care plans. Both a Licensed Nurse and the DON highlighted the importance of care plans for individualized care and communication.
A resident with cerebral infarction and reduced mobility was found with long, yellowish fingernails, indicating a failure in routine nail care. Despite being capable of understanding, the resident required assistance with personal care. Staff, including CNAs and LNs, acknowledged the oversight and the need for nail care to maintain hygiene, as per the facility's grooming policy.
A resident did not receive their prescribed medication, ropinirole, for three days due to the facility's failure to ensure timely delivery from the pharmacy. The medication was marked as unavailable, and there was no documentation of reordering. The DON indicated that the nurse should have contacted the pharmacy, but the facility's policy lacked guidance on reordering medications.
The facility failed to implement specific behavior monitoring for two residents prescribed psychotropic medications, increasing the risk of unnecessary medication use. One resident with Vascular Dementia and Major Depressive Disorder was on Seroquel without specific monitoring, while another with Major Depressive Disorder was on Lorazepam and Citalopram without behavior monitoring. The DON acknowledged the need for specific behavior indications to assess medication effectiveness, as required by the facility's policy.
A LTC facility failed to maintain a medication error rate below 5%, with errors involving two residents. A nurse administered famotidine without a physician's order and omitted cholecalciferol for one resident. Another resident received levothyroxine at the wrong time, affecting its effectiveness. These errors were identified through observations and interviews.
Expired needles and eyewash solutions were found in a medication storage room and cart, posing a risk of infection if used. A nurse confirmed the items were expired and should have been discarded. The facility's policy lacked guidance on discarding expired supplies.
A kitchen staff member failed to properly test disinfectants by not following the test strip instructions, which required a 10-second immersion. The Registered Dietician confirmed the correct procedure, but the facility lacked a policy on testing disinfectants.
The facility failed to properly thaw frozen meat, as observed during a survey. A plastic bag of frozen chicken was found floating in water on a kitchen counter, contrary to the facility's policy of thawing in the refrigerator or under running water. The Dietary Manager confirmed the improper method and stated that the cook knew the correct procedure.
The facility failed to ensure arbitration agreements were signed by responsible parties for two residents who lacked decision-making capacity. Despite assessments indicating incapacity, both residents signed agreements themselves. The DON confirmed that agreements should be signed by responsible parties when residents lack capacity.
The facility failed to ensure a pest-free kitchen environment, with multiple insects observed during food preparation. A staff member continued chopping pork despite an insect landing on it. Interviews revealed a lack of awareness and communication about pest control measures, and the facility's policy lacked specific guidelines for kitchen pest management.
Two CNAs failed to wear PPE while caring for a resident on Enhanced Barrier Precaution (EBP) with a urinary catheter, despite clear signage indicating the need for PPE. This was observed by the Director of Staff Development, who confirmed the requirement to prevent infection spread. The Infection Preventionist and DON acknowledged the protocol breach, which contradicted both facility policy and CDC guidelines.
The facility failed to maintain a comfortable temperature environment during an AC malfunction, affecting several residents. The maintenance department did not routinely check or document room temperatures, and staff areas had cooling units that were not offered to residents. The assistant director of nursing was unaware of the residents' complaints and the lack of temperature monitoring, leading to several rooms exceeding the federal temperature limit.
During an unannounced visit, unsecured containers of liquids and an overflowing sharps container were found in resident shower rooms, posing risks of ingestion and injury. Additionally, a water leak in the hallway near the east nursing station created a slip hazard. Staff interviews revealed confusion over responsibilities for managing these hazards, and the issues remained unresolved, posing risks to residents.
The facility failed to secure medication, treatment, and IV carts, allowing unauthorized access to medications and needles. During an unannounced visit, surveyors found an unlocked medication cart with insulin pens, an unattended treatment cart with medicated creams, and an unlocked IV cart with needles and labeled medication bags. Nursing staff acknowledged the carts should be locked to prevent unauthorized access, but the ADON could not provide a specific policy for safe medication storage.
A resident with functional quadriplegia and joint contractures did not have a person-centered care plan addressing repeated refusals of showers and skin treatments. Despite being dependent on staff for ADLs, the facility failed to document refusals or hold IDT meetings to investigate the reasons. Staff interviews confirmed the lack of documentation and care planning, violating facility policies on care planning and treatment refusal.
A resident with functional quadriplegia and joint contractures did not receive routine showers or bed baths as required, leading to a risk of skin infections and injuries. The resident was dependent on staff for personal care, but there was no care plan addressing these needs. Facility staff acknowledged issues with adherence to shower schedules and documentation, and an in-service was conducted for evening shift staff but not for the day shift.
A resident with functional quadriplegia and joint contractures did not receive ordered wound treatments on two consecutive days, leading to potential delayed healing and worsening of wounds. The resident was later found with maggots in her ear and sent to the hospital. Interviews revealed no documentation of treatment refusal or reasons for missed treatments, and the ADON confirmed the lack of documentation.
A resident with COPD, capable of making his own decisions, had his PHI disclosed without authorization when the social services director contacted his family to assist with discharge planning. The director of nursing acknowledged that permission should have been obtained, violating the facility's policy on third-party disclosure of PHI.
The facility failed to administer medications as ordered for two residents. A resident with anxiety received Ativan more frequently than prescribed, while another with osteomyelitis missed several doses of Cefazolin. The DON acknowledged these errors, which did not meet the facility's expectations.
A facility failed to develop a baseline nutrition care plan within 48 hours for a resident with COPD and moderate cognitive deficits. The dietary service supervisor initiated the care plan late and was unaware of the required timeframe. The registered dietitian expected timely gathering of food preferences, which were not included in the care plan, risking weight loss and health decline.
The facility failed to complete a comprehensive discharge care plan for a resident with diabetes mellitus type 2 and moderate cognitive impairment. Despite physician's orders for wound care and a discharge order with home health, the discharge care plan was not located or completed, as confirmed by the SSD and DON.
The facility failed to administer medications as ordered for two residents. One resident did not receive Lidocaine gel 4% every morning as prescribed, and another resident missed multiple doses of Lidocaine patches 4% due to refusal, being held, and unavailability. There was no documentation of physician notification or progress notes for the missed medications.
Inaccurate MDS Coding Due to Lack of Physician Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was admitted with diagnoses including dysphasia following a stroke. During the assessment process, the MDS nurse marked malnutrition on the MDS form without having the required physician documentation to support this diagnosis. Although the nurse had provided a query form for the physician to sign as supporting documentation, it had not been signed at the time the MDS was coded and submitted. Interviews with the MDS nurse and the Director of Nursing confirmed that physician documentation was necessary to accurately code malnutrition in the MDS, as this information is submitted to CMS for billing purposes. Review of facility policy and the CMS RAI MDS 3.0 Manual further supported the requirement for accurate and documented assessments. The deficiency resulted in the submission of inaccurate information to the federal database.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Implement Individualized Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive and individualized care plan to address fall prevention for a resident with severe cognitive impairment and high fall risk. The resident, diagnosed with dementia and muscle weakness, was unable to use the call light or effectively communicate needs, yet the care plan interventions focused on ensuring the call light was within reach and anticipating needs. Staff interviews revealed that the resident was often left unattended in his room, and the care plan did not include specific interventions such as not leaving the resident in a wheelchair unattended, despite his inability to call for help. On the date of the incident, the resident was left alone in his room in a wheelchair, resulting in a fall that caused a head injury and required hospital assessment. Staff were aware of the resident's fall risk status, but the resources available to them, such as the binder at the nurses station, did not provide individualized interventions. The care plan lacked specificity and did not address the resident's unique needs, contributing to the failure to prevent the fall.
Failure to Prevent Fall in High-Risk Resident with Cognitive Impairment
Penalty
Summary
A resident with muscle weakness and severe cognitive impairment, as indicated by a BIMS score of six, was identified as being at high risk for falls, with a Fall Risk Assessment score of 17. The resident's care plan included interventions such as anticipating needs, ensuring the call light was within reach, and providing assistance as needed. However, staff interviews revealed that the resident was unable to use the call light or effectively communicate needs, making some interventions ineffective. The resident was typically supervised at the nurses station or in the Director of Staff Development's office, where staff could monitor for safety, but on the day of the incident, the resident was left alone in his room without staff presence. During this unsupervised period, the resident fell from his wheelchair, sustained a head injury, and required hospital assessment. Staff acknowledged that the resident should have been left in an area where supervision was possible, given his high fall risk and inability to call for help. The facility's fall management policy required individualized care planning and ongoing evaluation of interventions, but the implemented strategies did not adequately address the resident's specific needs, resulting in a preventable fall with injury.
Resident Dignity Compromised During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) provided care to a resident and, during perineal care, held a soiled wipe with bowel movement approximately one to two inches from the resident's face. The resident had requested a brief change due to urination and questioned the CNA about the prolonged cleaning process. In response, the CNA showed the soiled wipe close to the resident's face and stated that the resident had a bowel movement. The resident reported feeling disrespected, humiliated, and uncomfortable, and subsequently requested a different CNA for care. Interviews with facility staff, including a licensed nurse, the assistant director of nursing (ADON), and the director of staff development (DSD), confirmed that the CNA admitted to showing the soiled wipe to the resident because the resident did not believe her. Both the ADON and DSD stated that this action was inappropriate and could be seen as a demeaning practice. Facility policy prohibits demeaning practices and requires staff to promote dignity and respect for residents.
Failure to Provide TV Remote Control Leads to Resident Altercation
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring that each resident in a shared room had access to their own TV remote control. On the date of the incident, there were only two TV remote controls available for three beds, and at the time, only one remote was present. One resident became upset after being unable to locate the TV remote control and asked his roommate about its whereabouts. This interaction led to a physical altercation, with the resident being struck in the chest by his roommate. The incident was subsequently reported as a physical abuse case to the California Department of Public Health (CDPH). Interviews with staff revealed that the resident had asked for assistance in locating the missing TV remote control, but no staff member assisted him. The Maintenance Director was unaware that the room was lacking sufficient TV remote controls and stated that no work order had been submitted for a replacement. Facility policy requires staff to assist residents in maintaining independence, dignity, and well-being, including accommodating individual needs and preferences. However, staff failed to provide the necessary support, resulting in the altercation between residents.
Failure to Provide Timely Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to implement an appropriate discharge plan for one resident who was transferred from the skilled nursing facility (SNF) to a general acute care hospital (GACH) and subsequently denied readmission to the SNF after being medically cleared for return. During a joint interview and record review with facility administration, it was revealed that there was no documented evidence of a discussion with the resident or responsible parties regarding a discharge notification or process. Additionally, when the GACH attempted to transfer the resident back to the SNF, the facility declined the transfer without providing a timely written discharge notice or informing the resident of their right to appeal the decision. This lack of notification and documentation was acknowledged by the facility administration during the interview.
Infection Control Deficiencies in Water Management, Bed Preparation, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection control practices in several areas, as observed during a survey. Firstly, the facility did not consistently check water temperatures or test the water for pathogens, as required by their Water Management policy. Interviews with the Maintenance Director and Infection Preventionist revealed that biological testing of the water supply was not conducted unless there was a cluster of infections, such as pneumonia or diarrhea, present in the facility. Additionally, the facility was unable to provide any logs for water temperature checks prior to October 24, 2024. Secondly, a personal belonging, specifically a comb, was found on a clean bed intended for a new resident admission. This was observed by a Licensed Nurse, who acknowledged that the bed should have been free of any items to ensure it was properly cleaned and disinfected. Lastly, a Licensed Nurse failed to perform hand hygiene after administering medications to one resident and before administering medications to another. This was contrary to the facility's Hand Hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections. The Infection Preventionist and Director of Nursing both confirmed the expectation for staff to perform hand hygiene between resident care and when entering and exiting resident rooms.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications prescribed to Resident 18, who was admitted with diagnoses including schizoaffective disorder and major depressive disorder. The medications prescribed were clonazepam, valproic acid, and olanzapine, intended to manage anxiety and schizophrenia. During interviews and record reviews, it was revealed that there were no consents for these medications in Resident 18's medical records. Licensed Nurse 1 and the Medical Records staff confirmed the absence of these consents, indicating a lapse in the facility's procedure for obtaining informed consent. Resident 18 was under conservatorship and unable to make medical decisions, necessitating informed consent from a responsible party. The Director of Nursing acknowledged the importance of informed consent to ensure the resident's family or decision-maker was aware of the medications being administered. The facility's policy on Behavior/Psychoactive Drug Management required verification of informed consent by the licensed nurse, which was not documented in this case, leading to the deficiency.
Failure to Complete POLST for Resident
Penalty
Summary
The facility failed to ensure that a POLST (Physician Orders for Life-Sustaining Treatment) was signed by the Responsible Party for one of the two sampled residents, identified as Resident 221. Resident 221 was admitted with a cognitive communication deficit and was determined by a physician to lack the capacity to understand and make decisions. The POLST, dated 10/5/24, was signed by the physician but lacked the required signature from the resident's legally recognized decision maker. Interviews with Licensed Nurse 31 and the Director of Nursing revealed that the POLST should have been completed and signed within 24 hours of admission to ensure the resident's end-of-life wishes were honored. The facility's policy mandates that a completed and signed POLST is a legal physician order that must include the signature of the resident or their representative. The failure to obtain the necessary signature resulted in a potential risk of not honoring Resident 221's end-of-life preferences.
Failure to Maintain Homelike Environment Due to Unstable Sink
Penalty
Summary
The facility failed to provide a homelike environment for a resident when a large opening was observed in the wall under the sink in the resident's bathroom. The resident, who was cognitively intact and admitted with diagnoses including muscle weakness and abnormalities of gait and mobility, expressed concern about the sink potentially falling. During an observation, the sink was found to be unstable, with a piece of plaster falling off when it was wiggled by a licensed nurse. The maintenance log indicated that the issue of the sink falling off the wall was reported months earlier, but the maintenance assistant had marked it as resolved after placing a seal around the sink. However, the maintenance director acknowledged that the hole in the wall was not aesthetically pleasing and needed fixing. The resident stated that such a condition would not be acceptable in her own home, indicating discomfort with the current state of her environment.
Failure to Provide Written Notice of Discharge
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident who was transferred to an acute care hospital. The resident, who had been admitted with a diagnosis of cirrhosis of the liver, was transferred on the order of a physician. However, the progress notes from the day of transfer did not document that the staff provided the required written notice of discharge. During interviews, two licensed nurses involved in the discharge process admitted that they did not provide the written notice, with one nurse unfamiliar with the discharge form. The Director of Nursing acknowledged that the notice should have been given according to the facility's policy, which mandates providing a Notice of Proposed Transfer and Discharge document prior to discharge.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident at the time of discharge to an acute care hospital, resulting in the resident not being fully informed of their bed-hold rights. The resident, who was admitted with cirrhosis of the liver, was transferred to a hospital following a physician's order. A review of the resident's medical record revealed no documentation of the staff providing the required written notice of bed-hold. Interviews with two licensed nurses involved in the discharge confirmed that they did not provide the notice. The Director of Nursing acknowledged that the notice should have been given, as per the facility's policy revised in July 2017, which mandates written notification of bed-hold options during transfers to acute care hospitals.
Inaccurate Medication Documentation in MDS
Penalty
Summary
The facility failed to ensure accurate documentation of medication in the Minimum Data Set (MDS) for a resident, leading to an increased risk of error in medical decisions based on the MDS. The deficiency involved Resident 88, who was admitted to the facility and whose MDS indicated that they received one insulin injection over the previous seven days. However, a review of Resident 88's medical record revealed no orders for insulin. During an interview, the MDS coordinator acknowledged the error, stating that the MDS was marked incorrectly, as there were no orders for insulin for Resident 88. This discrepancy was contrary to the facility's policy on utilizing the Resident Assessment Instrument process for accurate resident assessments.
Failure to Complete PASARR II for Resident with Mental Health Needs
Penalty
Summary
The facility failed to complete the PASARR II in a timely manner for a resident with mental health diagnoses, including schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. The resident was admitted with a suspected mental illness, as indicated by the PASARR I. However, the PASARR II was not completed due to a letter from the Department of Health Care Services stating the individual was unable to participate in the evaluation. The Director of Nursing acknowledged that the PASARR II should have been followed up by the MDS Coordinator. Interviews with the MDS consultant and MDS Coordinator revealed that the PASARR II was crucial for the resident's placement and referral for mental health services. Despite the letter indicating the inability to complete the Level II evaluation, no further PASARR reviews were conducted after the initial letter. The facility's policy required the MDS Coordinator to ensure updates to the PASARR, which was not adhered to in this case.
Failure to Develop Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement care plans for psychotropic medications for two residents, which could potentially hinder communication among healthcare providers regarding the residents' medication monitoring. Resident 47 was admitted with diagnoses of Vascular Dementia and Major Depressive Disorder and was prescribed Seroquel. However, there was no care plan in place for the Seroquel medication, as confirmed by a Licensed Nurse during an interview. Similarly, Resident 105, who was admitted with Major Depressive Disorder, was prescribed lorazepam and citalopram, but no care plan was developed for these medications. The Licensed Nurse acknowledged the importance of a care plan for effective communication among staff. The Director of Nursing also emphasized the necessity of care plans to individualize resident care and communicate specific interventions required. The facility's policy mandates the development of a baseline care plan within 48 hours of admission, which was not adhered to in these cases.
Failure to Provide Routine Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide routine nail care to a resident who was dependent on staff for personal care, leading to a deficiency in the provision of activities of daily living (ADL). The resident, who was admitted with diagnoses including cerebral infarction, ataxia, and reduced mobility, was observed with long, yellowish fingernails. Despite being capable of understanding and making decisions, the resident required assistance with personal care due to muscle weakness and slow response from a brain injury. During interviews, staff members acknowledged the resident's dependency and the need for assistance with personal care, including nail care. Observations and interviews with various staff members, including a Restorative Nursing Assistant, a Certified Nursing Assistant, a Licensed Nurse, and the Director of Nursing, revealed that the resident's long fingernails were not addressed, despite the facility's policy on grooming. The staff confirmed that CNAs and LNs were responsible for cutting residents' fingernails to maintain hygiene and prevent germ buildup. The Director of Nursing acknowledged that the resident's long fingernails should have been cut for upkeep and hygiene, indicating a lapse in following the facility's grooming policy.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of medication from the pharmacy for a resident, resulting in the resident not receiving their prescribed medication, ropinirole, for three consecutive days. The resident, who was admitted with a diagnosis that included chronic pain, had an order to take ropinirole twice daily for restless leg syndrome. However, the medication was not administered on October 1st, 2nd, and 3rd, as indicated in the Medication Administration Record. Progress notes from the facility revealed that the medication was marked as unavailable on these dates, with no documentation indicating that the medication was reordered from the pharmacy. The Licensed Nurse responsible for the resident's care was not available for an interview. During an interview, the Director of Nursing stated that the nurse should have contacted the pharmacy to request the medication and documented the call. The facility's policy on medication ordering and receiving did not provide guidance on reordering medications or ensuring medications are reordered before they run out.
Lack of Specific Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure specific behavior monitoring for the use of psychotropic medications for two residents, leading to an increased risk of unnecessary medication administration. Resident 47, diagnosed with Vascular Dementia and Major Depressive Disorder, was prescribed Seroquel without specific behavior monitoring documented in the physician's orders, medication administration record (MAR), or care plan. Licensed Nurse 1 acknowledged that the behaviors being monitored, such as mood changes, falls, and medication side effects, were not specific or appropriate for psychotropic medication monitoring. Similarly, Resident 105, diagnosed with Major Depressive Disorder, was prescribed Lorazepam and Citalopram without specific behavior monitoring in place. Licensed Nurse 1 confirmed the absence of specific behavior monitoring for these medications in the physician's orders, MAR, or care plan. The Director of Nursing recognized the importance of specific behavior indications to assess medication effectiveness and communicate the care plan to healthcare staff. The facility's policy on Behavior/Psychoactive Drug Management requires specific behavior manifestations to be included in psychoactive medication orders, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by three medication errors involving two residents. During a medication administration observation, a Licensed Nurse (LN) administered famotidine to a resident without a physician's order, as the medication was intended for another resident. This error was acknowledged by the LN, who realized the potential negative impact if the resident had been allergic to the medication. Additionally, the same LN failed to administer cholecalciferol (Vitamin D) to the same resident, despite an active physician's order for daily administration. Another medication error involved the administration of levothyroxine to a different resident at an incorrect time. The medication was given in the morning instead of the scheduled 1 P.M. time, which was necessary to ensure its effectiveness. The Director of Nursing confirmed that the medication should have been administered on an empty stomach, aligning with the scheduled tube feeding times. These errors were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to physician orders and proper medication administration protocols.
Expired Medical Supplies Found in Medication Storage
Penalty
Summary
The facility failed to ensure that medication storage rooms and carts were free from expired medical supplies, which could potentially lead to infections if used on residents. During an observation of a medication storage room, expired needles with various expiration dates were found mixed with non-expired needles. Additionally, expired eyewash solution bottles were discovered. A licensed nurse confirmed that these items were expired and should have been discarded. The facility's policy on medication storage did not provide guidance on discarding expired medical supplies. In a separate observation, expired needles were found in one of the medication carts. A licensed nurse acknowledged that using these expired needles could have caused infections in residents. The Director of Nursing confirmed that expired medical supplies would not be sterile and could contain bacteria, emphasizing that expired items should not be present in medication storage areas or carts. The facility's failure to remove expired supplies from these areas was a significant oversight.
Improper Testing of Kitchen Disinfectants
Penalty
Summary
The facility failed to ensure that a kitchen staff member, referred to as Cook 12, properly tested the kitchen disinfectants. During an observation, Cook 12 was seen testing the disinfectant in a red bucket used for sanitizing surfaces by dipping a test strip into the disinfectant and immediately pulling it out to check the color. Cook 12 stated that he believed the strip only needed to be dipped for one second. However, the directions on the test strip container specified that the strip should be immersed for 10 seconds before comparing the color while wet. When questioned, Cook 12 retested the disinfectant by immersing the strip for seven seconds, still not adhering to the instructions. An interview with the Registered Dietician confirmed that the kitchen staff should have held the test strip in the liquid for the full 10 seconds as per the instructions. The facility did not have a policy on testing the red bucket disinfectant.
Improper Thawing of Frozen Meat
Penalty
Summary
The facility failed to ensure that frozen meat was thawed appropriately, as observed during a survey. During an observation and interview with the Dietary Manager, it was noted that a plastic bag containing cubes of meat was floating in a container of water on a kitchen counter. The Dietary Manager identified the meat as frozen chicken and acknowledged that it was being thawed improperly in sitting water. The correct procedure, as per the facility's policy on Food Storage and Handling, is to thaw foods in the refrigerator or under running water. The Dietary Manager also stated that the cook responsible for placing the frozen chicken in standing water was aware that this was not the proper method for thawing frozen meats.
Failure to Ensure Proper Signing of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were signed by the responsible party for two residents who lacked the capacity to understand and make decisions. Resident 67, diagnosed with schizoaffective disorder, was admitted to the facility and signed an arbitration agreement despite a physician's assessment indicating the resident did not have the capacity to understand and make decisions. The staff member responsible for completing arbitration agreements was unavailable for an interview. Similarly, Resident 171, diagnosed with schizophrenia, signed an arbitration agreement even though a physician's assessment noted the resident could not make medical decisions. The Director of Nursing confirmed that if a resident lacks decision-making capacity, the arbitration agreement should be signed by the resident's responsible party. The facility's policy states that only residents with capacity at the time of admission may sign the arbitration agreement.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the food preparation area, as evidenced by multiple observations of insects in the kitchen. During an observation, a staff member was seen chopping roast pork while a winged black insect flew around and landed on the food. The staff member did not remove the contaminated piece of pork and continued with food preparation. Further observations revealed additional insects, including a small winged insect on the wall above the ice machine and other insects flying above and around the food being prepared for lunch. Interviews with facility staff highlighted a lack of awareness and communication regarding pest control measures. The Registered Dietician mentioned plans to install an air curtain to prevent flying insects from entering the kitchen, but the Maintenance Director was unaware of any pest concerns or plans for such an installation. A review of the facility's pest control policy, last revised in 2012, showed no specific guidelines for managing pests in the kitchen, indicating a gap in the facility's pest management practices.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to infection control policies when two Certified Nursing Assistants (CNAs) did not wear the required personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precaution (EBP). The resident, who was admitted with chronic kidney disease and urinary retention, had a urinary catheter in place. Despite a sign outside the resident's room indicating the need for PPE, the CNAs entered the room and repositioned the resident without donning gowns and gloves. This oversight was observed during a concurrent observation and interview with the Director of Staff Development (DSD), who confirmed that PPE should have been worn to prevent infection spread. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged the lapse in protocol during a joint interview. They confirmed that the expectation was for staff to follow the EBP sign instructions and use PPE when caring for residents with indwelling medical devices, as outlined in the facility's policy and the CDC guidelines. The facility's policy, dated August 2019, emphasized the use of enhanced standard and transmission-based precautions to reduce pathogen transmission, including multidrug-resistant organisms (MDROs).
Failure to Maintain Comfortable Temperature Environment
Penalty
Summary
The facility failed to maintain a comfortable temperature environment for residents during an air conditioning malfunction, affecting five out of seven residents interviewed. The air conditioning unit in the west/south hallway stopped working, and the temperature exceeded the federal regulation limit of 79 degrees Fahrenheit. The maintenance aide was aware of the issue but was unable to proceed with repairs or use alternative cooling methods without the administrator's permission, who was on vacation. Residents expressed discomfort due to the heat, and some had to rely on fans brought by their families. The maintenance department did not routinely check or document room temperatures, and there was no temperature log maintained as a proactive measure. The assistant director of nursing was unaware of the residents' complaints and the lack of temperature monitoring. Staff areas were equipped with fans and portable air conditioning units, but these were not offered to residents. The facility's policy required room temperatures to be maintained between 71 and 81 degrees Fahrenheit, but this was not adhered to during the AC malfunction. The director of maintenance acknowledged the AC issues and informed the administrator, who instructed the ordering of new AC units. However, the maintenance department did not document temperature checks, contrary to the facility's policy. The facility's failure to maintain a comfortable environment and document temperature checks resulted in several rooms exceeding the temperature limit, with some reaching as high as 90 degrees Fahrenheit.
Hazardous Conditions in Shower Rooms and Hallway
Penalty
Summary
The facility failed to maintain a hazard-free environment in several areas, as observed during an unannounced visit. In two of the three resident shower rooms, unsecured containers of liquids such as shampoo, body wash, and shaving cream were found. These containers were left unattended on metal shelves and handrails, with some open to the environment, posing a risk of ingestion by confused and cognitively impaired residents. The Director of Staff Development acknowledged the potential danger, noting that the shower rooms were unlocked and accessible to residents. Additionally, a red sharps container in one of the shower rooms was found overflowing with used razors, creating a risk of injury. Interviews with staff revealed confusion over responsibility for managing the sharps containers, with the housekeeping supervisor and central supply staff each indicating that nursing staff were responsible. A charge nurse confirmed the hazard, stating that the situation was unacceptable and posed a risk of injury to residents. Furthermore, a water leak was observed in the hallway near the east nursing station, with saturated towels and blankets on the floor and no warning signs present. The maintenance aide reported that the leak had persisted for a week due to a delay in obtaining a replacement part from the water dispenser company. Despite daily calls to the company, the issue remained unresolved, and no alternative solutions had been pursued. The Assistant Director of Nursing acknowledged that the leak should have been addressed immediately to prevent slips and falls.
Failure to Secure Medication and IV Carts
Penalty
Summary
The facility failed to secure medication, treatment, and intravenous (IV) carts, leading to unauthorized access to medications and IV needles. During an unannounced visit, surveyors observed an unlocked medication cart in the north hallway of the east unit, containing multiple medications and insulin pens. A licensed nurse acknowledged leaving the cart unlocked, admitting that it allowed unauthorized access to medications, which could be harmful. Additionally, a treatment cart was found unlocked and unattended, containing medicated creams and ointments. A treatment nurse was unaware of the cart's ownership and confirmed that treatment carts should always be locked to prevent unauthorized access. Further observations revealed an unlocked IV cart in the south hallway of the east unit, containing packaged needles and liquid medication bags labeled with resident names. The charge nurse confirmed that the IV cart should be locked to prevent unauthorized access to its contents. Interviews with nursing staff, including the Assistant Director of Nursing (ADON), highlighted the expectation that all carts should be locked when not in use to maintain safety. The ADON was unable to provide a specific policy for safe medication storage, relying instead on a CMS critical element pathway as their guideline.
Failure to Develop Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with functional quadriplegia and joint contractures, who was dependent on staff for activities of daily living (ADLs) such as turning, transferring, toileting, and showering. Despite the resident's cognitive abilities being intact, the facility did not address the resident's repeated refusals of care, including showers and skin treatments, in their care plan. This lack of a comprehensive care plan led to potential miscommunication and inconsistent care, which could delay wound healing and increase the risk of infections. The resident's clinical records and interviews revealed that the resident was offered showers on multiple occasions but refused them, yet there was no documentation or care plan addressing these refusals. The facility's shower book showed inconsistencies in documenting whether showers were offered or refused, and there was no evidence of interdisciplinary team (IDT) meetings to investigate the reasons behind the refusals. Additionally, the resident refused skin treatments multiple times, but again, no care plan was developed to address these refusals. Interviews with facility staff, including licensed nurses and the assistant director of nursing, confirmed that there was a lack of documentation and care planning for the resident's refusals of showers and skin treatments. The facility's policies on comprehensive person-centered care planning and refusal of treatment were not followed, as there were no updates or assessments made to address the resident's needs and refusals. The absence of a care plan for the resident's ADLs and refusals of care highlighted a significant deficiency in the facility's care planning process.
Failure to Provide Routine Showers and Hygiene Care
Penalty
Summary
The facility failed to provide routine showers and/or bed baths to a resident who was dependent on staff for activities of daily living (ADLs), including bathing. The resident, who was admitted with functional quadriplegia and joint contractures, was at risk for skin infections and injuries due to the lack of proper hygiene care. The resident's clinical record indicated a dependency on staff for personal care, yet there was no care plan addressing these needs. Observations and interviews revealed that the resident had not refused showers or bed baths, but was only offered a shower two out of seven scheduled opportunities in July, and none after returning from a hospital stay in August. Interviews with facility staff, including a Licensed Nurse (LN) and the Director of Staff Development (DSD), highlighted a lack of adherence to the facility's policy of offering showers at least twice a week. The DSD acknowledged complaints from residents about missed or delayed showers and confirmed that an in-service was conducted for evening shift staff, but not for the day shift. The Assistant Director of Nursing (ADON) emphasized the importance of documenting shower provision and addressing repeated refusals in the care plan. The facility's policies on showering and refusal of treatment were not followed, contributing to the deficiency in care.
Failure to Provide Ordered Wound Treatments
Penalty
Summary
The facility failed to provide wound treatments as ordered for a resident, leading to the potential for delayed healing and worsening of wounds. The resident, who was admitted with functional quadriplegia and joint contractures, had a care plan and physician orders for daily wound treatment on the left neck. However, the Treatment Administrative Record (TAR) indicated that wound treatments were not provided on two consecutive days. The resident was later found with maggots in her left ear and was sent to the hospital for evaluation. Interviews and record reviews revealed that the resident preferred to lift her own head during treatments due to pain, and there was no documented evidence of treatment refusal or reasons for missed treatments on the specified dates. The wound treatment nurse acknowledged the difficulty in treating the resident's neck area due to contractures but confirmed that treatments were not performed on the weekend. The registered nurse who provided treatment on a previous date did not notice anything unusual with the wound and emphasized the importance of daily wound care. The Assistant Director of Nursing (ADON) confirmed that wound treatments were not documented as completed on the specified dates and acknowledged the lack of documentation for treatment refusal. The facility's policy on skin and wound management requires licensed nurses to document the effectiveness of treatments, but this was not adhered to in this case. The facility's administrator and director of nursing were unavailable for interviews.
Unauthorized Disclosure of Resident's PHI
Penalty
Summary
The facility failed to safeguard a resident's protected health information (PHI) by disclosing it without proper authorization. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and had intact cognitive abilities as indicated by a BIMS score of 15, was capable of making his own decisions. Despite this, the facility's social services director contacted the resident's family, listed as the emergency contact, without the resident's permission. The resident stated that it was not an emergency and he did not want his family to know about his whereabouts. During an interview, the social services director acknowledged contacting the family without the resident's authorization, stating the intention was to gather information for the resident's discharge plan. The director of nursing confirmed that permission should have been obtained from the resident before contacting the family. The facility's policy on third-party disclosure of PHI, dated 12/1/12, mandates upholding residents' rights under federal and state health privacy laws, which was not followed in this instance.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for two residents. Resident 1, who was admitted with an anxiety disorder, was prescribed Ativan 0.5 mg to be taken once in the afternoon. However, the Controlled Drug Record indicated that Resident 1 received Ativan more than once a day on specific dates in June 2024. The Director of Nursing (DON) acknowledged that the physician's orders were not followed in this case. Resident 2, admitted with osteomyelitis of the left foot, had a physician's order for Cefazolin 2 grams to be administered intravenously every eight hours for a bacterial infection. The Medication Administration Record showed that the Cefazolin was not administered on four separate occasions in July 2024. The DON confirmed that the IV antibiotic was not given as ordered, which was not acceptable according to the facility's expectations.
Failure to Implement Timely Nutrition Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline nutrition care plan within 48 hours of admission for a resident during a complaint investigation. The resident was admitted with a history of chronic obstructive pulmonary disease (COPD) and had moderate cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The dietary service supervisor (DSS) acknowledged that the care plan was initiated late, on May 23, 2024, instead of within the required 48-hour timeframe. The DSS was unaware of the specific timeframe for initiating a baseline care plan, which is crucial for preventing weight loss by understanding the resident's meal preferences. The registered dietitian (RD) expected the DSS to gather information about the resident's food preferences upon admission and complete the care plan within 48 hours. The RD noted that the resident disliked oatmeal and spinach, as observed by the DSS on May 20, 2024, but this information was not included in the care plan. The facility's policy, dated November 2018, requires that a baseline care plan be completed within 48 hours of admission. The failure to timely incorporate the resident's food preferences into the care plan had the potential to lead to weight loss and a decline in health status due to poor meal intake.
Failure to Complete Comprehensive Discharge Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive discharge care plan was completed for Resident 2, who was admitted with a history of diabetes mellitus type 2 with circulatory complications. The Minimum Data Set (MDS) dated 1/24/24 indicated that Resident 2 had a moderate cognitive impairment, and there was no referral to a local contact agency for post-discharge transition. Resident 2's physician's orders included wound care treatments and a discharge order with home health for wound management. However, during an interview and record review on 5/7/24, the social services director (SSD) could not locate Resident 2's discharge care plan and acknowledged that it was not completed. The director of nursing (DON) also confirmed that the discharge care plan was missed and emphasized the importance of having it updated to ensure a safe discharge for Resident 2. The facility's policy and procedures titled
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medication orders for two residents were administered as ordered. Resident 1, who was admitted with diagnoses including muscle weakness and a fracture of the right femur head, was supposed to receive Lidocaine gel 4% topically every morning according to physician's orders dated 2/2/2024. However, during a medication administration observation on 4/18/2024, the Lidocaine gel was not administered by the licensed nurse. Resident 1 also stated that he did not remember receiving the medication every morning. The licensed nurse confirmed that the medication should have been administered and acknowledged that there was no documentation of physician notification or progress notes regarding the unavailability of the medication. Resident 2, admitted with diagnoses including osteoarthritis, was to receive 4 Lidocaine patches 4% to the lower back and 1 Lidocaine patch 4% to the neck and cervical spine every morning as per physician's orders dated 12/1/2023. The medication administration record (MAR) for April 2024 indicated that the Lidocaine patches were not given on 4/16, 4/17, and 4/18, with reasons including refusal by the resident, being held, and unavailability. There was no documentation in the nursing progress notes indicating that the physician was notified of the missed medications. Both the licensed nurse and the Director of Nursing acknowledged that the physician should have been notified and documentation should have been made in the resident's chart when medications were not administered as ordered.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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