The Rowland
Inspection history, citations, penalties and survey trends for this long-term care facility in Covina, California.
- Location
- 330 W. Rowland Street, Covina, California 91723
- CMS Provider Number
- 056117
- Inspections on file
- 38
- Latest survey
- May 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Rowland during CMS and state inspections, most recent first.
Two residents did not have their IV site or TPN tubing properly labeled with the date, time, and initials as required by facility policy. One resident's peripheral IV site lacked labeling upon dressing change, and another resident's TPN tubing was not labeled when hung. Nursing staff and the DON confirmed these omissions during interviews and observations.
Multiple residents receiving oxygen therapy and respiratory treatments were found with equipment such as oxygen tubing, nebulizer tubing, and nasal cannulas in unsanitary conditions, including being placed on the floor or not stored in clean bags. In addition, required safety signage for oxygen use was not posted outside a resident's room. Staff interviews confirmed these practices were inconsistent with facility policy and infection control standards.
Two residents were placed on bedrails without documented safety assessments, physician orders, or informed consent, contrary to facility policy. One resident with cognitive impairment and another with intact cognition both had bedrails installed without attempts at alternatives or proper documentation, as confirmed by staff interviews and record reviews.
A nurse administered five scheduled medications to a resident with severe cognitive impairment and a feeding tube earlier than the prescribed time, outside the facility's allowed one-hour window. The DON confirmed that this practice was not in accordance with facility policy, which requires medications to be given within one hour before or after the scheduled time to ensure effectiveness.
A nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses earlier than the scheduled time, resulting in a medication error rate of 17.86%, which exceeded the acceptable threshold. The facility's policy and the DON confirmed that medications should be given within a specific time window to prevent errors.
Surveyors found that a medication cart was left unlocked and unattended by an LVN, and a resident with COPD and other conditions was keeping prescribed inhalation medication in their bedside drawer without proper assessment or authorization. The DON and facility policies confirmed that medications must be secured and not kept at the bedside unless specific procedures are followed.
Surveyors identified that two of four kitchen sanitization buckets were not maintained at the correct chemical concentration, and required checks were not documented. Additionally, expired salsa containers were found in the refrigerator, and opened pasta noodles in dry storage were not labeled with open or use-by dates, contrary to facility policy. The Dietary Supervisor confirmed the importance of proper labeling and sanitization to ensure food safety.
Multiple residents requiring isolation or enhanced barrier precautions did not have proper signage or PPE carts outside their rooms, and staff failed to consistently use required PPE during care activities. A disposable gown was left hanging inside a room instead of being discarded, and the facility lacked a water management diagram to assess Legionella risk, all contrary to facility policy and orders.
A resident with severe cognitive impairment and total dependence for eating was assisted with meals by a CNA who stood over the resident rather than feeding at eye level, contrary to facility policy and staff expectations. Both the CNA and DON confirmed that feeding should occur at eye level to maintain dignity and proper monitoring.
A resident with hemiplegia and muscle weakness was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible on the resident's strong side. Staff confirmed the resident could not access the call light, resulting in a failure to accommodate the resident's needs.
A resident with significant medical conditions and moderately impaired cognition did not have an Advance Directive or AD Acknowledgement Form in their medical record. Staff interviews and policy review confirmed these documents should be present and updated with each admission or readmission, but they were missing from both the paper and electronic records.
A CNA was hired without a documented background check through the OIG database, contrary to facility policy requiring such checks to prevent employment of individuals with a history of abuse, neglect, or exploitation. Interviews with the DSD and DON confirmed the omission and the importance of pre-employment screening for staff and resident safety.
A resident with multiple chronic conditions and an indwelling Foley catheter was found with the catheter tubing not secured to the thigh, as required by facility policy and care plan. Both nursing staff and the DON confirmed the tubing was not properly attached, and the securement device was not taped, contrary to established procedures intended to prevent pulling and injury.
A resident with a biliary drain was found to have yellow biliary fluid leaking onto the floor beneath the drainage bag. Nursing staff acknowledged that the drainage bag should not be leaking, and the DON confirmed this posed an infection control concern. Facility policy required proper management of biliary drains to prevent such incidents.
A resident with multiple chronic conditions was receiving Lovenox for DVT prophylaxis when a consultant pharmacist recommended specifying a duration of therapy. The facility did not document that the attending physician was notified of this recommendation, contrary to policy, resulting in the recommendation not being addressed.
A resident with cognitive impairment and multiple diagnoses received antibiotics for a UTI without documented symptoms or meeting facility criteria, as required by the Antibiotic Stewardship Program. Staff interviews and record reviews confirmed the absence of necessary documentation and failure to follow established protocols for monitoring and documenting changes in condition.
A facility failed to follow its hand hygiene protocols when a CNA did not wash their hands after interacting with a resident diagnosed with C. diff. The resident was on contact isolation, requiring strict adherence to handwashing procedures. Despite removing protective gear, the CNA exited the room without washing hands, contrary to the facility's policy, which mandates handwashing with soap and water after contact with residents with infectious diarrhea.
Two residents in a LTC facility were found to have cigarettes and lighters in their possession, smoking unsupervised despite requiring supervision due to mental health and vision impairments. The facility failed to implement its smoking policy, creating potential fire hazards, especially with an oxygen machine present in one resident's room.
The facility failed to maintain safe food handling practices, with an ice scoop stored in a container with a brown liquid, leading to the distribution of contaminated ice to residents. Additionally, food storage practices were inadequate, with items not dated or labeled, increasing the risk of food-borne illnesses.
The facility failed to transmit MDS assessments within 14 days for 23 residents, as required. The Assistant Administrator, responsible for the task, did not realize the due dates, leading to the delay. Additionally, the facility had not trained other MDS staff on the transmission process, as per their policy.
The facility failed to provide proper care for GT management for two residents, leading to potential infection risks. One resident's GT tubing was left open, and another's GT site lacked a required dressing, contrary to care plans and facility policy.
The facility failed to manage oxygen therapy properly for several residents, as observed in unlabeled oxygen tubing and improper nasal cannula placement. This deficiency involved residents with conditions like COPD and respiratory failure, where oxygen tubing lacked date labels, risking infection, and nasal prongs were not correctly positioned, affecting oxygen delivery.
The facility failed to provide dialysis emergency kits for two residents requiring dialysis services, placing them at risk for excessive bleeding. Observations revealed the absence of these kits at the residents' bedsides, confirmed by nursing staff. The DON admitted the lack of policies to ensure kit availability.
The facility did not post accurate nurse staffing information in a prominent location, as required. Staffing details were found inside the North Nurses' Station, inaccessible to residents, family, and visitors. The Director of Staff Development was unaware of the requirement for accessible posting, leading to potential misinformation about staffing levels.
The facility failed to implement Gradual Dose Reductions (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. This oversight led to the potential inappropriate use of psychotropic drugs, affecting the residents' well-being. The facility did not adhere to its policy requiring PRN orders for antipsychotic medications to be reassessed every 14 days.
The facility failed to implement a comprehensive infection prevention and control program, lacking measures to monitor Legionella and other pathogens in water systems. Additionally, a resident with a Foley catheter was not provided with necessary Enhanced Barrier Precautions, such as signage and PPE, increasing the risk of infection.
A facility failed to include a resident's Advance Directive (AD) in their medical chart, despite the resident having both an AD and a POLST. The resident was alert and oriented, with intact cognitive abilities. Interviews with the Social Services Director and Director of Nursing revealed that the facility's policy required the AD to be prominently displayed in the medical record, which was not done, posing a risk of not honoring the resident's wishes.
A resident with dementia and epilepsy was left exposed during a bed bath by a CNA, who failed to follow the facility's policy of covering the resident and changing bath water as needed. The privacy curtain was open, and another CNA entered the room, further compromising the resident's privacy.
A facility failed to implement its policy on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who preferred Chinese, was communicated with by an LVN using body language, without a communication board at the bedside. The Activities Director confirmed the absence of necessary communication tools, which could lead to unmet needs.
A resident with a history of falls and requiring assistance with daily activities waited 31 minutes for help after activating the call light. Despite the facility's policy to respond within five to six minutes, staff interviews confirmed the delay, posing a risk of the resident attempting to move unassisted, potentially leading to a fall or injury.
A facility failed to implement interventions for a resident's positioning preference, potentially delaying wound healing. The resident, with a non-healing wound on the left ankle, preferred lying on her left side. Despite staff observations and interviews confirming this preference, care plans lacked interventions to manage it, contrary to the facility's wound care policy.
A resident with moderate cognitive impairment developed redness on her toes due to inadequate repositioning, despite having a care plan that included a pressure-reducing device and a turning program. Staff interviews confirmed the resident's preference to lie on her left side, and observations showed she remained in this position for extended periods, contrary to the facility's policy on pressure ulcer prevention.
A resident with spinal stenosis and bilateral artificial knee joints did not receive restorative services as ordered by the MD. The resident's Treatment Administration Record showed missed ambulation sessions, confirmed by staff interviews. This failure to follow the facility's policy on Restorative Services placed the resident at risk for contractures or a decline in ADL function.
A resident with a Foley catheter was not provided necessary care as per their care plan, which required the catheter to be secured to the inside of the thigh. Observations and staff interviews confirmed the catheter was not properly secured, contrary to facility policy, potentially leading to complications.
A resident with a fluid restriction order due to hyponatremia had their fluid intake improperly monitored, resulting in consistent overconsumption. Facility staff were unaware of the restriction and did not accurately measure fluid intake, contrary to the facility's policy requiring coordination between dietary and nursing staff.
A resident with multiple health conditions, including dementia and heart disease, received crushed enteric coated Aspirin due to an LPN's lack of awareness that such medications should not be crushed. The LPN routinely crushed the resident's medications because the resident could not swallow whole pills. The facility's policy required a reference list of medications not to be crushed, which was not followed.
The facility failed to maintain the required temperature in the Medication Refrigerator (MR) in Medication Storage Room 1, as observed by an LVN. The MR thermometer showed temperatures outside the acceptable range, and the LVN was unsure if the thermometer was broken. This non-compliance with the facility's policy could compromise medication effectiveness.
Failure to Label IV and TPN Sites and Tubing per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for infusion therapy in the care of two residents. For one resident with a history of gangrene and peripheral vascular disease, the peripheral intravenous (IV) site was not labeled with the date and initials upon insertion or dressing change, as required by facility policy. This omission was confirmed during observation and interview with nursing staff, who acknowledged that the labeling was necessary for infection control and to track when the dressing was last changed. The resident's care plan and facility policy both specified the need for dating and initialing the IV site dressing. For another resident receiving total parenteral nutrition (TPN) through a central venous catheter due to diagnoses including bladder cancer and anemia, the TPN administration set was not labeled with the date and time when it was hung. Observation and interviews with nursing staff and the DON confirmed that the tubing was unlabeled, contrary to facility policy, which required labeling to ensure proper infection control and to document when the tubing was last changed. Both deficiencies were identified through direct observation, record review, and staff interviews.
Failure to Maintain Safe and Sanitary Respiratory Care Practices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents requiring oxygen therapy and related respiratory equipment. For one resident with pulmonary fibrosis and diabetes, observations revealed that both the oxygen tubing and nebulizer tubing were found on the floor, and a CNA confirmed that the tubing had become contaminated due to contact with the floor. The Director of Nursing (DON) acknowledged that such contamination poses an infection control risk, as equipment on the floor is considered contaminated and could be a source of infection for the resident. Another resident with a history of lung cancer, pneumonia, and chronic kidney disease was observed with oxygen nasal prongs not properly placed in the nostrils, and the nebulizer face mask was left on the bedside table instead of being stored in a clean bag. The DON and a nurse both stated that the nasal prongs should be in the nostrils to ensure the resident receives the prescribed oxygen, and the nebulizer mask should be stored in a clean bag to prevent contamination. Additionally, a resident with asthma and hypertension was found to be receiving oxygen therapy without the required "Oxygen No Smoking, No Open Flames" sign posted outside the room, contrary to facility policy and staff statements regarding fire safety. A further observation involved a resident with diabetes and chronic kidney disease, where the nasal cannula was found on the floor with the prongs directly touching the surface. Nursing staff confirmed that the cannula should be stored in a plastic bag when not in use to prevent cross-contamination. The facility's policy and procedure on oxygen administration and respiratory supply require that all supplies not in use be placed in a bag for infection control, and that appropriate signage be posted when oxygen is in use. These deficiencies were identified through direct observation, staff interviews, and review of facility records and policies.
Failure to Follow Bedrail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedrails for two residents. For one resident with dementia, Alzheimer's disease, and moderately impaired cognition, full bedrails were observed in use without any documented assessment for safety risk, physician's order, or informed consent prior to installation. The resident was dependent on staff for most activities of daily living, and staff confirmed that the required assessment and documentation were not completed before applying the bedrails. For another resident with anxiety disorder and muscle weakness, both upper side rails were found raised, and the resident reported never being asked for consent regarding their use. The resident had intact cognitive skills and required some assistance with daily activities. Facility staff, including the DON, confirmed that no alternatives were attempted, no physician's order was obtained, and no informed consent was documented before the bedrails were installed. The facility's policy required assessment, consideration of alternatives, and consent prior to bedrail use, but these steps were not followed for either resident.
Medications Administered Outside Prescribed Time Window
Penalty
Summary
A deficiency occurred when a licensed vocational nurse administered five scheduled medications to a resident through a gastrostomy tube earlier than the prescribed time. The medications, which included Tylenol Extra Strength, Ferrous Sulfate Liquid, Folic Acid, Sertraline, and Docusate Sodium, were all scheduled for 9:00 a.m. but were given at 7:45 a.m. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness. The facility's policy allows for medications to be given within one hour before or after the scheduled time, but this administration was outside that window. The resident involved had significant medical needs, including paraplegia, depression, dementia with severely impaired cognition, and was dependent on staff for all activities of daily living. The resident received nutrition via a feeding tube. The Director of Nursing confirmed that medications should be administered within the specified time frame to ensure therapeutic effectiveness and avoid potential harm, as outlined in the facility's policy.
Medication Error Rate Exceeded Due to Early Administration
Penalty
Summary
The facility failed to maintain a medication error rate at or below five percent during medication administration for one resident. On the observed date, a licensed vocational nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment, paraplegia, depression, and dementia. All five medications were scheduled for administration at 9 a.m., but the nurse administered them at 7:45 a.m., which was earlier than the prescribed time. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness and that it was important to follow the correct timing to prevent medication errors. A review of the resident's records confirmed the resident's dependence on staff for all activities of daily living and the use of a feeding tube for nutrition. The facility's policy required adherence to the five rights of medication administration, including the right time. The Director of Nursing confirmed that medications should be given within one hour before or after the scheduled time and that deviations could result in medication errors. This incident resulted in five medication errors out of twenty-eight opportunities, leading to a medication error rate of 17.86%.
Failure to Secure Medications and Improper Resident Medication Storage
Penalty
Summary
Surveyors observed that a medication cart containing residents' medications was left unlocked and unattended in a hallway by a Licensed Vocational Nurse (LVN) during a medication pass. The LVN admitted to not locking the cart when retrieving medication from the medication room, acknowledging that the cart should have been secured for safety. The Director of Nursing (DON) confirmed that the medication cart needed to be locked if it was outside the licensed nurse's view. Facility policy and procedure documents reviewed by surveyors also required absolute security of medications, including locking medication carts when out of sight. Additionally, a resident with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD) was found to have a prescribed inhalation medication stored in their bedside drawer. The resident stated they kept their medication in the drawer, and the LVN confirmed this, stating that medications should not be kept at the bedside for safety reasons. The DON stated that residents were not allowed to have medication at their bedside unless they had been assessed for safe self-administration. Facility policy required written physician orders and interdisciplinary committee determination for residents to self-administer or retain medications in their rooms.
Deficient Food Handling and Storage Practices Identified
Penalty
Summary
The facility failed to maintain safe food handling practices in several areas, as observed during a survey. Two out of four red sanitization buckets used in the kitchen were not maintained at the correct chemical concentration, as required by the manufacturer's guidelines of 200-400 ppm. Additionally, the log for checking the sanitizer concentration showed that the required check at 8:00 a.m. was not performed. The Dietary Supervisor confirmed that these buckets are used to sanitize kitchen surfaces. Further deficiencies were observed in food storage and labeling. One plastic container of expired red tomato salsa and one container of green salsa, both past their use-by dates, were found in the walk-in refrigerator. In the dry storage area, an open bag of penne pasta noodles and an open bag of spaghetti pasta noodles were not labeled with an open date or use-by date. The facility's policies require that leftover or opened foods be labeled and dated to ensure proper use and safety. The Dietary Supervisor acknowledged the importance of these practices to prevent serving expired or unsafe food.
Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to implement and follow infection prevention and control procedures for multiple residents requiring isolation or enhanced barrier precautions (EBP). For one resident with a Stage 3 pressure injury, there was no EBP signage or isolation cart with personal protective equipment (PPE) outside the room, despite physician orders and care plan interventions requiring these measures. The Infection Prevention Nurse confirmed that signage and PPE carts should have been present to ensure staff compliance with EBP protocols. Another resident with a gastrostomy tube and severely impaired cognition was observed receiving medication administration from an LVN who did not don a gown, as required under EBP. The LVN acknowledged the omission and stated that a gown should have been worn to prevent cross-contamination. Additionally, a resident with a biliary drain and central line did not have EBP signage posted outside the room, despite orders and facility policy indicating that such signage is necessary to communicate required precautions to staff and visitors. Further deficiencies included a disposable gown left hanging on the doorknob inside the room of a resident on contact isolation for a multidrug-resistant organism (MDRO), contrary to facility policy that requires immediate disposal of used gowns. The facility also lacked a water management program with a diagram or text assessing where Legionella or other waterborne pathogens could grow, as required by their own policy. These failures were confirmed through staff interviews and review of facility policies and procedures.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to promote dignity while assisting a resident with meals by not feeding the resident at eye level to maintain face-to-face contact. The resident, who had diagnoses including Parkinson's disease, dementia, and diabetes mellitus, was admitted with severely impaired cognition and required total assistance with eating. During an observation, a CNA was seen standing over the resident while providing feeding assistance, rather than sitting at eye level as required by facility policy and best practices for maintaining resident dignity. Interviews with the CNA and the DON confirmed that staff are expected to feed residents at eye level to allow for proper monitoring and to uphold the resident's dignity. The facility's policy on meal assistance specifically states that residents should not be fed while staff are standing over them, emphasizing the importance of safety, comfort, and dignity during mealtimes. The failure to follow this policy was directly observed and acknowledged by staff.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia affecting the right dominant side, muscle weakness, and anxiety was found with their call light on the floor and out of reach. The resident's care plan specified that the call light should be kept within reach, particularly on the side of the resident's strong arm and hand. During observation, the resident was lying in bed with a contracted right hand, and the call light was not accessible. Certified Nurse Assistant 3 confirmed that the resident could not reach the call light and acknowledged it should have been placed within reach of the resident's functional side. Further review of the resident's records indicated that the resident was dependent on staff for activities of daily living and had intact cognition. The facility's policy and procedures required that call lights be kept within reach of residents at all times. The Director of Nursing also stated that the call light should be placed close to the resident's good arm and hand to ensure timely response to needs. The failure to keep the call light within reach was contrary to both the care plan and facility policy.
Failure to Maintain Advance Directive Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive (AD) and AD Acknowledgement Form were present in the medical record for one of three sampled residents. Upon review of the resident's admission record, it was found that the resident, who had a history of malignant neoplasm of the lung, pneumonia, and chronic kidney disease, did not have a copy of the AD or the AD acknowledgement form in either the paper chart or the electronic medical record. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the RN Supervisor and the DON confirmed that the AD and AD acknowledgement form should be updated and included in the resident's chart with each admission or readmission. The facility's policy also required that residents be provided with information about their rights regarding medical treatment and advance directives upon admission, and that this information be prominently displayed in the medical record. The absence of these documents in the resident's record was verified during the survey process.
Failure to Complete Required Background Check Prior to Hire
Penalty
Summary
The facility failed to conduct a required background check for one of two randomly selected employees, a Certified Nurse Assistant (CNA), prior to hire as mandated by the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy. During a review of the CNA's employee file, there was no documented evidence that the Office of Inspector General (OIG) database check or any background check was completed before or after the CNA's hiring date. Interviews with the Director of Staff and Development and the Director of Nursing confirmed that background checks are necessary for staff and resident safety, and that the administrator was responsible for performing these checks prior to employment. The facility's policy requires that no individual with a history of abuse, neglect, exploitation, or misappropriation be employed, but this process was not followed in this instance.
Foley Catheter Tubing Not Secured as Required by Facility Policy
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with the catheter tubing not secured to the thigh, contrary to the facility's policy and procedure. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease, was dependent on staff for most activities of daily living and required an indwelling Foley catheter for urinary retention and skin management. The care plan specified that staff should monitor the position of the catheter tubing to ensure proper urine flow, and the order summary required licensed staff to check every shift that the catheter was in place. During observation and interviews, it was confirmed by both a registered nurse and the Director of Nursing that the catheter tubing was not secured as required, and the securement device was not taped. The facility's policy indicated that the tubing should be attached to the resident's leg to prevent pulling and injury. This failure to follow established procedures had the potential to result in catheter-related complications for the resident.
Failure to Prevent Biliary Drainage Leak and Maintain Infection Control
Penalty
Summary
A deficiency occurred when a resident with a biliary drain was found to have biliary fluid on the floor beneath their drainage bag. The resident, who had diagnoses including bladder cancer and anemia, required substantial to maximal assistance for mobility and had an order in place to monitor and document biliary drain output three times daily. Documentation showed the drain output was being recorded, but during an observation, yellow liquid from the biliary drain was seen on the floor. The LVN present confirmed that each nurse is responsible for emptying the drainage bag during their shift and acknowledged that the drainage should not be leaking onto the floor. The Director of Nursing confirmed that biliary fluid should not be present on the floor due to infection control concerns, as organisms in the fluid could be a source of illness or infection and could be transmitted by contact. The facility's policy on biliary drain management emphasized the importance of proper care to prevent infection and ensure appropriate drainage. The failure to prevent biliary drainage from leaking onto the floor constituted a lapse in infection control practices for the resident requiring biliary drain care.
Failure to Act on Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's medication regimen review (MRR) recommendation for a resident who was receiving Enoxaparin Sodium Injection (Lovenox) for deep vein thrombosis prophylaxis. The pharmacist's MRR specifically recommended that a duration of therapy be provided for the use of Lovenox. However, there was no documentation that the attending physician was notified of this recommendation, as confirmed by both a Licensed Vocational Nurse and the Director of Nursing during interviews and record reviews. The resident involved had a medical history including osteomyelitis, diabetes mellitus, and chronic obstructive pulmonary disease, and required varying levels of assistance with activities of daily living. The facility's policy and procedure required that the consultant pharmacist's findings and recommendations be reported to the physician and documented accordingly, but this process was not followed in this instance. As a result, the pharmacist's recommendation regarding the medication regimen was not communicated or acted upon.
Failure to Follow Antibiotic Stewardship Policy for UTI Treatment
Penalty
Summary
The facility failed to implement its policy on antibiotic use and change in condition for one of five sampled residents, resulting in the administration of antibiotics without meeting established criteria. A resident with diagnoses including Alzheimer's disease, dementia, and depression was admitted and later had an abnormal urinalysis. Subsequently, a physician ordered Cephalexin for a urinary tract infection, and the medication was administered for ten days. However, the resident's medical record did not document any of the required signs or symptoms of a symptomatic UTI as outlined in the facility's Infection Criteria Checklist, and there was no urinary catheter in place. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the necessary documentation of UTI signs and symptoms was not present in the resident's record. Both staff members acknowledged the importance of completing infection criteria and tracking to ensure appropriate antibiotic use and compliance with the facility's Antibiotic Stewardship Program. Review of facility policies indicated that changes in resident condition and antibiotic use should be thoroughly documented and tracked, but these procedures were not followed in this case.
Failure to Adhere to Hand Hygiene Protocols for C. diff Isolation
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) on Handwashing and Hand Hygiene, specifically in the case of a certified nursing assistant (CNA 1) who did not wash their hands after interacting with a resident diagnosed with Clostridium difficile (C. diff) infection. This resident, identified as Resident 3, was admitted with end-stage renal disease and enterocolitis due to C. diff. The care plan for Resident 3 included contact isolation precautions to prevent the spread of infection, which required staff to adhere to strict hand hygiene protocols. During an observation, CNA 1 was seen moving Resident 3's overbed table and adjusting bed linens without washing their hands afterward. Despite removing their isolation gown and gloves, CNA 1 exited the room without performing hand hygiene, only washing their hands at the nurses' station sink. This action was contrary to the facility's P&P, which mandates handwashing with soap and water after contact with residents with infectious diarrhea, such as C. diff, before exiting the isolation room. Interviews with other CNAs and the Infection Prevention Nurse (IPN) confirmed the necessity of handwashing before exiting the room of a resident on contact isolation. The IPN emphasized that handwashing with soap and water is recommended over alcohol-based hand sanitizers to prevent the spread of C. diff. The facility's P&P on Handwashing and Hand Hygiene clearly outlines these procedures, highlighting the importance of hand hygiene as a primary means to prevent infection spread.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who were smokers. Resident 8, who was on Seroquel for paranoid schizophrenia and had a history of hearing voices telling him to harm himself and others, was found to have cigarettes and lighters in his room. He smoked unsupervised, contrary to the facility's smoking policy, which required staff supervision due to his mental health condition. The Director of Nursing (DON) was unaware of Resident 8's possession of smoking materials and confirmed that he had not been evaluated for safe smoking practices. Resident 36, who had poor vision and was legally blind, also had cigarettes and lighters in her possession and smoked without supervision. Her care plan indicated she required supervision due to her impaired vision and the presence of an oxygen machine in her room, which posed a significant fire hazard. Despite these risks, Resident 36 was allowed to keep smoking materials and was not monitored during smoking, as required by her care plan and the facility's smoking policy. The facility's failure to implement its smoking policy and ensure proper supervision of these residents created a potential for serious harm, including fire hazards, due to the presence of smoking materials in the residents' rooms. The survey team identified these deficiencies during their investigation, highlighting the facility's noncompliance with safety protocols for residents who smoke.
Removal Plan
- Cigarettes and cigarette lighters were removed from Resident 8 and Resident 36's rooms and placed under supervision of the charge nurses (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]).
- Resident 8 and Resident 36's CPs were updated by LVNs and the DON.
- Resident 8 and Resident 36 were educated by the facility's DON on smoking and cigarette lighter safety and why cigarette lighters cannot be in residents' possession.
- Resident 8 was informed by the ADM for safety and importance of using appropriate and approved ashtrays for cigarette butts (the part of the cigarette that was left after it had been smoked).
- The Supervised Designated Smoking Area Map for smokers was created which included the following: a. Patio in front of the facility by the front entrance. b. Patio outside the facility by the back entrance/parking lot. c. Patio outside the facility exit located between rooms [ROOM NUMBERS].
- The Designated Smoking Time Schedule for residents who required smoking supervision was created which included the following: a. Morning after breakfast from: 8:00 am to 8:30 am, 9:00 am to 9:30 am and 11:30 am to 12:00 pm b. Afternoon after lunch from: 1:00 pm to 1:30 pm, 2:30 pm to 3:00 pm and 4:30 pm to 5:00 pm c. Evening after dinner from: 6:00 pm to 6:30 pm
- The Director of Staff Development (DSD) provided an in-service to 26 Certified Nursing Assistants (CNAs), nine LVNs, four RNs, one Social Services Designee, one Medical Records Designee, three activity staff, and one housekeeper on the facility's revised smoking policies regarding supervised smoking, designated smoking areas, and designated smoking time schedules.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain safe food handling practices, specifically in the storage and sanitation of an ice scoop and its container. The ice scoop was stored in a container that contained approximately 100 milliliters of a brown liquid substance, which the scoop was in contact with. This contaminated scoop was used by Certified Nursing Assistants (CNAs) to fill ice chests that were distributed to the North and South Nursing Stations, affecting 42 out of 90 residents who received ice during breakfast and lunch. The facility had no records of cleaning and sanitizing the ice scooper container as per their policy. Additionally, the facility did not ensure safe food storage practices. In one of the kitchen freezers, food items were not dated when received, and mixed salad dressings were not discarded after their indicated shelf life. In the kitchen's dry and canned storage area, food items were also not dated, and in one of the unit refrigerators, stored food items were not labeled with the resident's name and date. These practices placed residents at risk for food-borne illnesses. The survey team identified an Immediate Jeopardy situation due to the facility's failure to meet food safety standards, specifically regarding the storage of food equipment in a sanitary condition. The ice scoop and container were not cleaned and sanitized daily, as required by the facility's policy. This oversight led to the distribution of contaminated ice to residents, posing a risk of water-borne illnesses.
Removal Plan
- The ice scoop and ice scoop container were placed in the kitchen dishwasher to be cleaned and sanitized.
- The two ice chests in the north and south nursing stations were sanitized.
- The ice machine located in the facility's dining room was locked and put into temporary out of service.
- All residents' water pitchers and cups for 90 residents (total census) were replaced with new/uncontaminated water pitchers and cups.
- The Dietary Supervisor (DS) in-serviced four dietary aides on the cleaning of the ice scooper and ice scooper container.
- 200 pounds of ice was purchased by the ADM.
- A new ice scooper and container sanitation log was created for the dietary aides on duty to log in the time of the day when they sanitize the ice scooper and the ice scooper container. The DS would check the log to ensure the ice scooper and the ice scooper container were sanitized daily.
- A water company service had been contracted and scheduled maintenance of the ice machine and replacement of water filter every six months.
- The facility's (P&P) titled, Cleaning and Sanitizing the Ice Scooper and Container for Ice Machine, was revised to include daily cleaning of the ice scooper, the ice scooper container and document in the cleaning log.
- A new clear ice scooper container with lid and new ice scooper was purchased.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit assessments within 14 days of completion for 23 sampled residents. This deficiency was identified during a review of the Minimum Data Set (MDS) 3.0 Final Validation Report, which showed that the assessments for these residents were submitted late. The MDS Nurse indicated that the Assistant Administrator (AADM) was responsible for transmitting the MDS assessments to the Centers for Medicare and Medicaid Services (CMS). However, the AADM admitted to not realizing the due dates for these assessments, resulting in the delay. The AADM further acknowledged that the facility had not provided training to other MDS staff on how to transmit MDS assessments to CMS. The facility's policy and procedure, which was undated, stated that MDS staff were responsible for timely transmission of MDS data in accordance with the MDS RAI Instruction Manual. The failure to transmit these assessments on time had the potential to result in inaccurate information being submitted to CMS, which could affect the facility's star rating and quality of care.
Deficiencies in Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for gastrostomy tube (GT) management for two residents, leading to potential risks of infection and adverse consequences. For Resident 193, who was admitted with diagnoses including subdural hemorrhage and epilepsy, the GT tubing was observed with the end open and hanging on a pole, contrary to the care plan that required it to be capped to prevent infection. This was confirmed by interviews with the Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Nursing, all of whom acknowledged the need for the tubing to be covered to maintain the quality of the feeding formula and prevent contamination. Similarly, for Resident 195, who had diagnoses including senile degeneration of the brain and altered mental status, the GT site was found without a cover or dressing, despite the care plan's requirement for daily cleaning and dressing to prevent infection and skin irritation. The Infection Preventionist Nurse and Director of Nursing confirmed that the site should be covered as ordered to protect the skin and prevent accidental pulling during movement. The facility's policy on enteral feedings also emphasized the importance of securing the tube and applying a new dressing as per physician orders.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure on Oxygen Administration. This deficiency was observed in four residents who were receiving oxygen therapy. The facility did not label the oxygen tubing with the date it was changed or started, which is crucial for infection control and ensuring the tubing is changed on schedule. This oversight was noted in the cases of Residents 189, 31, and 2, where the oxygen tubing lacked proper labeling, potentially leading to bacterial growth and infection. Resident 189, admitted with conditions including hypertension and morbid obesity, was observed with oxygen tubing that was not labeled with the date of change. Similarly, Resident 31, who had diagnoses including congestive heart failure and respiratory failure, also had unlabeled oxygen tubing. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed the necessity of labeling the tubing to prevent infection. Resident 2, diagnosed with chronic obstructive pulmonary disease, had an oxygen concentrator with coiled tubing in a plastic bag, also lacking a date label, which was acknowledged by the Registered Nurse Supervisor as a risk for bacterial growth. Additionally, Resident 64, who was dependent on supplemental oxygen due to chronic respiratory failure, was found with nasal prongs improperly positioned under the chin, rather than in the nostrils, during an observation. This improper placement meant the resident was not receiving the prescribed amount of oxygen. The Registered Nurse Supervisor admitted to not checking the proper placement of the nasal prongs during rounds. The facility's policy indicated that nasal cannula should be properly positioned and monitored by licensed nurses, which was not adhered to in this instance.
Lack of Dialysis Emergency Kits for Residents
Penalty
Summary
The facility failed to ensure that a dialysis emergency kit was readily available for two residents who required dialysis services. Resident 85, who was admitted with diagnoses including diabetes mellitus and dependence on renal dialysis, was observed without a dialysis emergency kit at their bedside. The Treatment Nurse confirmed the absence of the kit, which is essential for controlling bleeding at the dialysis access site in an emergency. This oversight placed Resident 85 at risk for excessive bleeding, which could lead to serious harm or death. Similarly, Resident 44, admitted with end-stage renal disease and dependence on renal dialysis, also lacked a dialysis emergency kit at their bedside. The Registered Nurse Supervisor confirmed the absence of the kit, emphasizing its importance in managing potential bleeding emergencies. The Director of Nursing later acknowledged that the facility did not have policies and procedures in place to ensure the availability of dialysis emergency kits at the bedside, further contributing to the deficiency.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information reflecting the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. This deficiency was observed during a recertification survey, where it was noted that the staffing information was not posted in a prominent location for two out of four days. Specifically, the staffing information was found inside the North Nurses' Station, and no information was posted in the South Nurse's Station, making it inaccessible to residents, family, and visitors. During interviews, the Director of Staff Development (DSD) admitted to projecting the actual hours worked by nursing staff and was unaware that the information needed to be posted in a location accessible to residents, family, and visitors. The facility's policy and procedures indicated that staffing information should be posted in a prominent location within two hours of the beginning of each shift. The DSD acknowledged that the current posting location inside the North Nurses' Station was not accessible to those outside the station, which could mislead residents and visitors about the staffing levels available for resident care.
Failure to Implement GDR and Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five residents on psychotropic drugs were free from unnecessary medication. Specifically, the facility did not attempt a Gradual Dose Reduction (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. These practices had the potential to lead to inappropriate use of psychotropic drugs, affecting the residents' physical, emotional, and psychosocial well-being. Resident 25, admitted under hospice care for end-stage Alzheimer's disease, was prescribed Seroquel and Haloperidol for agitation. Despite only two episodes of agitation being recorded, there was no documented attempt at GDR for Seroquel, nor was there an evaluation for the continued use of Haloperidol beyond 14 days. The Director of Nursing acknowledged the oversight in following up on the discontinuation of these medications. Resident 47, with severe cognitive impairment, had been on a consistent dose of Seroquel since 2022 without any documented GDR attempts, despite minimal behavior incidents. Additionally, Residents 13, 41, and 77 had PRN orders for antianxiety medications that exceeded the 14-day limit without reevaluation by a physician. The facility's policy required PRN orders for antipsychotic medications to be reassessed every 14 days, which was not adhered to in these cases.
Inadequate Infection Control and Water Safety Management
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, specifically in monitoring and managing water safety to prevent the growth of Legionella and other waterborne pathogens. During interviews, the Administrator admitted that the facility did not monitor water management, as they believed there were no stagnant waters, and acknowledged the absence of preventative measures for Legionella. The Infection Preventionist Nurse confirmed that although the facility had a policy for Legionella surveillance and detection, there were no implementations for such surveillance. The facility's policy indicated that all pneumonia cases diagnosed 48 hours after admission should be investigated for Legionnaire's disease, but this was not being followed. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a Foley catheter, which increased the risk of infection. The resident's care plan required continuous monitoring, signage on the door, and proper PPE usage to prevent cross-infection. However, observations revealed that there was no EBP signage posted outside the resident's room, nor was there a PPE cart provided. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed that these precautions were necessary and should have been in place to prevent the spread of infection.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to adhere to its policy on Advance Directives (AD) by not ensuring a current copy of a resident's AD was included in the medical chart. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including a urinary tract infection, hyperlipidemia, and constipation. The resident was alert and oriented, with intact cognitive abilities, and had both an AD and a Physician Orders for Life Sustaining Treatment (POLST) form. However, during a review, it was found that the AD was not present in the resident's medical chart, only the POLST was available. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the facility's policy required the AD to be prominently displayed in the medical record. The SSD acknowledged that the ADPA form was not specific enough to indicate whether the resident had an AD or a POLST, which could lead to the resident's wishes not being respected if the AD differed from the POLST. The DON confirmed that the absence of the AD in the medical chart posed a risk of not honoring the resident's wishes. The facility's policy stated that information about the existence of an AD should be prominently displayed in the medical record, which was not followed in this case.
Privacy Breach During Bed Bath
Penalty
Summary
The facility failed to maintain privacy for Resident 28 during a bed bath, which was observed by surveyors. Resident 28, who was admitted with diagnoses of dementia and epilepsy, had moderately impaired cognition and required assistance with personal care. During the bed bath, Certified Nursing Assistant 6 (CNA 6) did not adequately cover Resident 28's body, leaving the resident exposed while washing different areas. The privacy curtain was left open, and another CNA entered the room, further compromising Resident 28's privacy. The facility's policy and procedure for giving a bed bath were not followed by CNA 6. The policy required washing one part of the body at a time, covering each area after washing, and changing the bath water as necessary. However, CNA 6 used the same water for washing different parts of Resident 28's body and did not cover the resident appropriately, leading to exposure. This lack of adherence to the facility's procedures resulted in a deficiency related to maintaining the privacy and dignity of Resident 28.
Failure to Implement Translation Services for LEP Resident
Penalty
Summary
The facility failed to implement its policy and procedure on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who was admitted with a wedge compression fracture, unspecified hearing loss, and a history of falling, had the capacity to understand and make decisions. The resident's preferred language was Chinese, as indicated in the Minimum Data Set. However, during an observation, the resident called out in Spanish, and the Licensed Vocational Nurse (LVN) communicated by pointing to body parts, which did not ensure the resident understood the purpose of the medication being administered. There was no communication board at the bedside to facilitate communication in a language the resident could understand. The Activities Director (AD) confirmed that the facility had communication boards in Spanish, Arabic, Filipino, and Mandarin, which were supposed to be at the bedside for residents who could not communicate in English. The AD stated that without these boards, residents' needs would not be met. The facility's policy indicated that individuals with LEP should have meaningful access to information and services, and that their needs and questions should be accurately communicated to the staff. The failure to provide appropriate communication tools for the resident with LEP had the potential to result in unmet needs.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to respond to a call light and provide timely assistance to a resident, identified as Resident 289, who required help with activities of daily living. Resident 289 was admitted with a history of falling and a wedge compression fracture of the first lumbar vertebra. The resident's care plan indicated the need for assistance, and the Minimum Data Set assessment confirmed the requirement for maximal assistance with sitting on the side of the bed and moderate assistance with sit-to-stand and toilet transfers. Despite these needs, the resident's call light was observed to be on for 31 minutes without a response, during which time the resident expressed the need for help to use the restroom. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor, revealed that the facility's policy required call lights to be answered within five to six minutes. Both staff members acknowledged that a 30-minute wait was unacceptable and posed a risk of the resident attempting to get up unassisted, potentially leading to a fall or injury. The facility's policy and procedure on call light response were not adhered to, resulting in a deficiency in providing timely care and assistance to Resident 289.
Failure to Address Resident's Positioning Preference Delays Wound Healing
Penalty
Summary
The facility failed to develop and implement interventions to address a resident's positioning preference, which potentially delayed wound healing. The resident, who had a non-healing wound on the left lateral and medial ankle, preferred to lie on her left side. Despite this preference, the facility did not create care plan interventions to address the resident's positioning, which was crucial given the location of the wound. Observations over several days showed the resident consistently lying on her left side, even when repositioned by staff, indicating a lack of effective intervention to prevent pressure on the wound. Interviews with staff, including a CNA and a wound care nurse, confirmed the resident's preference to lie on her left side and the need for repositioning to aid wound healing. However, the care plans reviewed did not include specific interventions to manage the resident's positioning preference, despite the presence of an open wound with visible metal. The facility's policy on wound care required reviewing the care plan for special needs, but this was not adequately addressed for the resident's situation.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for Resident 16, who was observed to have redness at the base of the left lateral toe and the right big toe. Resident 16, who was admitted with diagnoses including benign neoplasm of the endocrine pancreas and infection due to internal orthopedic prosthetic devices, was noted to have moderate cognitive impairment and required extensive assistance with bed mobility. Despite having a care plan that included a pressure-reducing device for the bed and a turning and repositioning program, observations over several days showed that Resident 16 consistently remained on her left side, which was her preferred position. Interviews with staff, including a CNA and the Wound Care Nurse, confirmed that Resident 16 preferred lying on her left side, and attempts to reposition her were often unsuccessful. The facility's policy on the prevention of pressure ulcers emphasized the need for frequent repositioning, especially for residents with cognitive impairments. However, the staff did not effectively implement these preventive measures, as Resident 16 was observed to remain in the same position for extended periods, leading to the development of redness on her toes, indicating potential pressure ulcer formation.
Failure to Provide Restorative Services as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure on Restorative Services by not providing restorative services in accordance with the Medical Doctor's order for a resident. The resident, who was admitted with spinal stenosis and bilateral artificial knee joints, required assistance with activities of daily living and had an order for a Restorative Nursing Assistant program for ambulation five days a week. However, the Treatment Administration Record for May 2024 showed blank spaces on several dates, indicating that the ambulation program was not performed as ordered. Interviews with the Restorative Nursing Aide and the Director of Nursing confirmed that the blank spaces in the Treatment Administration Record meant the treatment was not completed. The Director of Nursing acknowledged that not performing the RNA exercises as per the MD's order placed the resident at risk for contractures or a decline in ADL function. The facility's policy on Restorative Services required staff to assist residents with prescribed physical therapy exercises, which was not followed in this case.
Failure to Secure Foley Catheter as Per Care Plan
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a Foley catheter, as indicated in the resident's care plan. Resident 189, who was admitted with diagnoses including a urinary tract infection and benign prostatic hyperplasia, was observed with a Foley catheter that was not secured to the inside of the thigh as required by the care plan. This lack of proper securing of the catheter was noted during an observation in the resident's room. Interviews with nursing staff confirmed that the Foley catheter should have been secured to prevent accidental pulling, which could cause trauma to the resident. The facility's policy and procedure for catheter care also indicated that the catheter should be secured with a leg strap to reduce friction and movement at the insertion site. The failure to adhere to these guidelines and the resident's care plan had the potential to result in catheter-related complications for Resident 189.
Failure to Monitor Fluid Intake for Resident on Restriction
Penalty
Summary
The facility failed to accurately monitor the fluid intake of a resident, identified as Resident 30, who was on a physician-ordered fluid restriction. Resident 30 was admitted with diagnoses including hypertension, anemia, and atrial fibrillation, and had a care plan that required fluid intake monitoring due to hyponatremia. Despite these requirements, the facility's records showed that the resident's fluid intake consistently exceeded the prescribed limits over several days, with nursing and dietary records documenting intakes far above the allowed 1200 cc per day. Interviews with facility staff revealed a lack of awareness and proper measurement practices regarding the resident's fluid restriction. Certified Nurse Assistant 6 was unaware of any residents on fluid restriction, and Licensed Vocational Nurse 4 admitted to estimating fluid intake without using a measuring cup. The facility's policy required coordination between dietary and nursing staff to ensure compliance with fluid restrictions, but this was not effectively implemented, leading to potential complications for the resident due to electrolyte imbalance.
Failure to Properly Administer Enteric Coated Medication
Penalty
Summary
Licensed Vocational Nurse 2 (LVN 2) failed to ensure that enteric coated Aspirin was not crushed during medication administration for Resident 7. The resident, who was admitted to the facility with conditions including gastroesophageal reflux disease, dementia, and atherosclerotic heart disease, was observed to have their medications crushed and mixed with applesauce by LVN 2. This included the enteric coated Aspirin, which is designed to prevent degradation by gastric acids and should not be crushed. During an interview, LVN 2 admitted to always crushing Resident 7's medications due to the resident's inability to swallow whole pills, but was unaware that enteric coated Aspirin should not be crushed. The Director of Nursing confirmed that delayed release or enteric coated medications should not be crushed and that an alternative form should be sought with a physician's order. The facility's policy indicated that a list of medications not to be crushed should be available for reference, but this was not adhered to in this instance.
Medication Storage Temperature Non-Compliance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the storage of medications, specifically in maintaining the required temperature in the Medication Refrigerator (MR) in Medication Storage Room 1 (MSR 1). During an observation and interview, it was noted that the MR thermometer displayed a temperature of 62 degrees Fahrenheit, which was outside the required range of 36 to 46 degrees Fahrenheit. Licensed Vocational Nurse 4 (LVN 4) confirmed the temperature reading and expressed uncertainty about whether the thermometer was functioning correctly. Upon rechecking, the temperature was found to be 56 degrees Fahrenheit, still outside the acceptable range. LVN 4 acknowledged that a malfunctioning thermometer could potentially compromise the effectiveness or stability of the medications stored in the MR. Further interviews with Registered Nurse Supervisor 2 (RN Sup 2) reinforced the importance of maintaining the MR temperature within the specified range to prevent the risk of affecting medication potency and bacterial growth. The facility's policy and procedure on Storage of Medication clearly stated that the MR must have working thermometers, and licensed nurses are required to log the temperature twice daily to ensure compliance. The failure to maintain the MR at the required temperature could lead to medications becoming unstable and ineffective, posing a risk to patient safety.
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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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