The Villas At Saratoga Skilled Nsg & Assisted Lvg
Inspection history, citations, penalties and survey trends for this long-term care facility in Saratoga, California.
- Location
- 20400 Saratoga-los Gatos Rd, Saratoga, California 95070
- CMS Provider Number
- 055435
- Inspections on file
- 29
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at The Villas At Saratoga Skilled Nsg & Assisted Lvg during CMS and state inspections, most recent first.
A resident with dementia and anxiety, who had documented memory problems, was allegedly pushed into a w/c and punched in the face by the spouse, as witnessed and reported by a CNA to an LVN. The LVN separated the spouse from the resident and notified the LVN supervisor, and the MD later recommended monitoring for emotional distress. Despite documentation of the incident and the CNA’s description of the resident as shaken and fearful, facility leadership, including the DON and administrator, determined that no abuse occurred and did not report the allegation to law enforcement, the ombudsman, or the state agency, contrary to facility policy requiring immediate reporting of suspected abuse.
Surveyors identified multiple infection control lapses, including unlabeled wash basins left on floors and in sinks in shared bathrooms that staff confirmed were in current use, contrary to facility policy requiring single-resident-use items to be labeled and properly stored. In the oxygen storage room, an LVN and the IP acknowledged that emergency O2 tanks and room air concentrators were cluttered on the floor with no designated or labeled areas to separate clean from used equipment, and clean items were not bagged to protect from dust. Additionally, a housekeeping staff member removed gloves after leaving a resident room, then handled a housekeeping cart and a personal cell phone and placed the used gloves in a uniform pocket without performing hand hygiene, despite facility policy and the IP’s expectation that staff perform hand hygiene after glove removal and between tasks.
A resident with parkinsonism and spasmodic torticollis received ordered ST three times weekly for four weeks for PO trials, aspiration precautions education, and swallow compensatory strategies, but no person-centered care plan addressing ST was developed or implemented. Review of clinical documentation showed no ST care plan, and both the DOR and DON confirmed its absence, stating therapy staff should have created it in accordance with facility policy requiring an IDT-developed, comprehensive person-centered care plan for each resident.
Surveyors found unsecured oxygen (O2) equipment and environmental hazards when an unused E tank was left free-standing on the floor in a resident room instead of being secured in a portable cart, as confirmed by an LVN and the DON. In the oxygen supplies storage room, surveyors and an LVN observed a cluttered, unorganized area with multiple E tanks standing freely on the floor, several room air concentrators with long electrical cords on the floor, and no separation between clean and used oxygen equipment. Facility policy required storage rooms to be kept clean, oxygen cylinders to be stored in racks, carts, or approved stands, never left free-standing, and not stored in resident rooms or living areas.
A resident with CHF, chronic kidney disease, and HTN had previously received PCV13 but was not subsequently offered or given a follow-up PNA vaccine as recommended by CDC guidelines. Review of the immunization record showed no documentation of PCV20 or PCV21 administration after the earlier PCV13 dose, and the IP confirmed that the recommended follow-up vaccine was not offered. This was inconsistent with the facility’s own P&P, which require that all residents be assessed and offered pneumococcal vaccines upon admission and when indicated.
A resident with an order for PRN acetaminophen for mild pain was found after a fall exhibiting signs and symptoms of pain, including moaning, groaning, and inability to lift an arm. Despite these symptoms and verbal complaints of pain, nursing staff did not administer the ordered pain medication prior to the resident's transfer to the hospital. Review confirmed the medication was not given as required by facility policy.
A resident with severe cognitive and physical impairments, requiring moderate to maximum assistance for ADLs, experienced an unwitnessed fall resulting in a hip fracture after attempting to use the toilet without staff help. The care plan lacked person-centered interventions specifying the required assistance, and staff were not present to provide support at the time of the incident.
A resident was unable to have quiet time in their room due to persistent noise from metal plates located on the facility's driveway. The noise occurred whenever people stepped on or vehicles passed over the plates, and observations confirmed the issue. The maintenance supervisor acknowledged that the plates were not tightly fitted, resulting in disruptive sounds that affected the resident's environment, contrary to facility policy on comfortable sound levels.
A resident with severe cognitive impairment and multiple medical conditions was found with several medications left unattended in their room, prepared by an LVN who intended for the resident to take them later. No licensed staff were present at the time, and interviews with the LVN, DON, and consultant pharmacist confirmed that medications should not be left unattended and must be stored in locked compartments according to facility policy.
A resident with dementia and severe cognitive impairment eloped from the facility after staff failed to provide adequate supervision and several exit doors were not alarmed. The resident, who had a history of confusion and wandering, was able to leave undetected and was later found outside with injuries. Staff were unaware of the resident's risk and did not implement frequent monitoring until after the incident.
Two residents reported mistreatment by CNAs, including verbal disrespect and physical abuse. In both cases, nursing staff failed to suspend the accused CNAs as required by facility policy, instead either taking no action or only changing assignments, contrary to the established procedures for handling abuse allegations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
The facility failed to ensure proper food safety and dietary management, exposing residents to potential contaminants and unsanitary practices. Observations included improper food storage, preparation, and sanitation, as well as a lack of standardized recipes and emergency menus for therapeutic diets. Additionally, fortified diets were not properly communicated or served to residents, despite being physician-ordered.
The facility's food and nutrition services staff failed to follow recipes and procedures, leading to potential food safety risks. A Dietary Aide did not measure ingredients correctly for pureed salmon, and another did not check the temperature of tuna salad before serving. Additionally, staff were not properly trained in using test strips for dishwashing sanitization and calibrating food thermometers, risking bacterial contamination and foodborne illnesses.
The facility failed to maintain sanitary conditions in food service, with an old meal left in the microwave, dirty fans in food prep areas, and a damaged measuring cup used for meal preparation. The Registered Dietitian and Foodservice Director acknowledged these issues, highlighting lapses in routine checks and equipment maintenance.
The facility failed to ensure that three residents were informed about having an advance directive (AD) and did not have completed Physician Orders for Life-Sustaining Treatment (POLST) forms. The Social Service Director confirmed the absence of ADs and incomplete POLST forms for these residents. The Director of Nursing also confirmed the lack of advance directives and incomplete POLST forms. The facility's policy requires inquiry about advance directives upon admission and assistance in establishing them if they do not exist.
The facility failed to follow its bed rail policy for 12 residents, with several using grab bars without necessary physician orders or care plans. Observations revealed that some residents had grab bars installed without documentation, while others lacked care plans despite having physician orders. The DON confirmed these deficiencies, which were not in line with the facility's policy requiring care plans for bed rail use.
The facility did not adhere to standardized recipes for pureed meals and lacked proper emergency food supply procedures. A resident on a pureed diet did not receive the specified menu items, and the emergency binder lacked menus for therapeutic diets. The RD and FSD acknowledged these deficiencies, which could impact nutritional intake and emergency preparedness.
The facility did not ensure standardized recipes for the puree diet were followed, potentially altering the palatability and nutritional value of food for twelve residents. A cook was observed preparing pureed salmon without accurate measurements, leading to a watery mixture that required additional thickener. The Registered Dietitian confirmed that staff should adhere to approved recipes and measurements to maintain accurate calorie counts and nutrition.
The facility did not ensure 21 residents received their physician-ordered Fortified Diets, which are crucial for maintaining nutritional status. During meal service, the Dietary Aide failed to communicate the need for fortified meals, resulting in residents not receiving the correct diet. The Registered Dietitian and Director of Nursing acknowledged the oversight, highlighting a lapse in the facility's protocol for ensuring accurate meal delivery.
The facility failed to maintain the dignity of three residents during meal assistance and catheter management. A CNA was observed standing while feeding two residents, contrary to the policy requiring staff to sit for resident comfort and dignity. Additionally, a resident's foley catheter bag was left uncovered, visible from multiple angles, which the DON confirmed should have been covered to maintain dignity.
A facility failed to develop a care plan for a resident's use of Clopidogrel, a medication for preventing blood clots, despite the resident's diagnoses of Atherosclerotic Heart Disease and drug-induced Cushing's syndrome. The absence of a care plan was confirmed by the ADON and DON, who acknowledged that it should have been part of the resident's treatment plan, as required by the facility's policy.
A facility failed to follow its policy for enteral tube feeding when a nurse did not pause the continuous tube feeding while adjusting a resident's bed to a flat position. The facility's policy requires the feeding to be paused during such adjustments to prevent complications. The DON confirmed the policy, which mandates the head of the bed to be at 30-45 degrees during feeding unless contraindicated.
A facility failed to ensure complete dialysis communication reports for a resident with end stage renal disease, missing post dry weight documentation on several occasions. Both an LVN and the DON confirmed the incompleteness and emphasized the need for proper communication with the dialysis center, as per the facility's policy.
The facility failed to ensure accurate accountability of controlled drugs, resulting in discrepancies between the controlled drug record (CDR) and the medication administration record (MAR) for three residents. Medications were signed out on the CDR but not documented on the MAR, with no evidence of administration found in the progress notes. This failure to adhere to the facility's policy and procedures for medication documentation was confirmed by the ADON and DSD during the survey.
A resident with dementia and other mental health conditions was prescribed PRN Seroquel without a 14-day limit, leading to administration beyond the allowed period. The DON confirmed the oversight, noting the absence of a stop date and the need for re-evaluation. The facility's policy requires PRN psychotropic medications to be limited to 14 days unless extended with documented rationale.
A survey found a medication error rate of 8.82% in a facility, exceeding the acceptable 5% threshold. Errors included a resident self-administering two puffs of an inhaler instead of one, and another resident not properly instructed on inhaler use, with cranberry juice given instead of water for rinsing. Additionally, a nasal spray was under-administered. These errors were confirmed through interviews and record reviews, indicating non-compliance with prescriber orders and facility policies.
The facility failed to implement proper infection control practices, including not covering a dirty linen container, not disinfecting a CPAP mask, and not labeling urinals in a shared bathroom. Additionally, a nurse did not change gloves after touching non-treatment items, and another did not use the correct disinfectant for a glucometer. These actions were contrary to facility policies and could compromise resident health and safety.
The facility did not maintain a coffee machine in a safe condition, with missing buttons and exposed wires, impacting the dietary staff's ability to prepare coffee safely. The issue was noted in the Quality Assurance and Performance Improvement Plan, and the facility was awaiting a replacement machine.
The facility was found to have seven resident rooms that did not meet the required minimum size of 80 square feet per resident. Despite this, nursing care and services were not affected, and both residents and staff reported no concerns about the room sizes.
A resident with mobility issues was not evaluated for fall risk upon admission, and during a transfer using a Hoyer lift, staff failed to use the correct sling and did not support the resident, resulting in a fall and hospitalization. The facility's protocols for safe transfers were not followed, contributing to the incident.
Failure to Report Staff-Reported Abuse Allegation to Required External Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely notify law enforcement, the ombudsman, and the state agency after a staff-reported allegation of abuse involving one resident. The resident, admitted with dementia and anxiety, had documented short- and long-term memory problems. On the date of the incident, a CNA reported to an LVN that the resident’s husband was rough and upset with the resident for not sitting in a wheelchair to go to the dining hall and made a gestured motion toward the resident’s face; the CNA observed the resident appearing shaken and fidgeting afterward. A change of condition note documented the incident involving the husband, resident, and CNA, and the MD recommended monitoring the resident for signs and symptoms of emotional distress. The resident’s care plan was updated with an entry for an alleged hand gesture to the resident’s face with interventions. In subsequent interviews, the LVN supervisor confirmed the change of condition documentation and stated that, based on the facility’s investigation concluding no abuse occurred, he did not report the allegation to required external entities and was unsure if the facility reported it at all. The LVN who received the initial report stated she separated the husband from the resident, reported the allegation to the LVN supervisor, and that the supervisor immediately began an investigation and discussed it with the administrator and DON, but she did not know if it was reported outside the facility. The CNA later stated he witnessed the husband push the resident into a wheelchair and punch the resident’s face near the chin area, saw the resident’s body shaken and fearful, and believed it was abuse that should have been reported. The DON and regional administrator both acknowledged that, based on their determination that no abuse occurred and the husband’s denial, the allegation was not reported to the ombudsman, law enforcement, or state agency, despite facility policy requiring immediate reporting of suspected abuse to these entities.
Infection Control Lapses in Resident Care Items, Oxygen Storage, and Hand Hygiene
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to resident care items, equipment storage, and staff hand hygiene. Surveyors observed multiple unlabeled wash basins in shared resident bathrooms and sinks, including basins on the floor and in sinks, which a CNA confirmed were currently in use for residents. The CNA stated that basins should be labeled with the resident’s name when rooms and bathrooms are shared, should not be left on the floor or in sinks when not in use, and should be cleaned and stored in the resident’s closet after each use. The facility’s infection preventionist (IP) also stated that resident care items, including wash basins, should be labeled with the resident’s name and stored in a plastic bag in the resident’s closet when not in use, consistent with the facility’s policy that single-resident-use items are for single-resident use only and must be labeled with the resident’s name and/or room number. The deficiency also includes improper organization and separation of clean and used oxygen equipment, and failure of housekeeping staff to perform hand hygiene after glove removal. In the oxygen supply storage room, surveyors and an LVN observed a cluttered, unorganized space with multiple free-standing emergency O2 tanks and room air concentrators on the floor, with no designated or labeled areas to distinguish clean from used equipment. The LVN stated they were unable to identify clean from used equipment and that staff should organize and separate these supplies, while the IP stated the room should be clean and organized, with separate areas and signage for clean and used equipment, and clean oxygen equipment stored in plastic bags to protect from dust, in line with facility policy. In a separate observation, a housekeeping staff member removed gloves after exiting a resident room, then touched the housekeeping cart and a personal cell phone and placed the used gloves in a uniform pocket without performing hand hygiene. The housekeeping staff member acknowledged that hands should have been washed after glove removal, and the IP stated that all staff should perform hand hygiene before and after glove use and between tasks, consistent with the facility’s hand hygiene policy requiring hand hygiene after removing gloves.
Failure to Develop Person-Centered Speech Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for speech therapy (ST) services for one resident. The resident was admitted with diagnoses including parkinsonism and spasmodic torticollis, conditions associated with movement difficulties and muscle contractions. An order dated 11/7/2025 directed ST three times per week for four weeks for PO trials, education on aspiration precautions, and swallow compensatory strategies, and this order was discontinued on 12/6/2025. Review of ST notes showed the resident received ST services as ordered. However, review of the resident’s clinical documentation revealed no evidence of a person-centered care plan addressing ST services. During concurrent record review and interviews, the director of rehabilitation confirmed the resident received ST for four weeks and acknowledged there was no person-centered care plan for ST, stating that therapy staff should have developed and implemented one. The DON also confirmed the absence of an ST care plan and stated therapy staff should have developed and implemented a person-centered care plan when the resident received ST. The facility’s policy on comprehensive person-centered care plans requires the IDT, in conjunction with the resident and/or representative, to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident’s rights to participate and receive services included in the plan of care.
Unsecured Oxygen Cylinders and Disorganized Oxygen Storage Area
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental safety involving oxygen (O2) equipment. During facility rounds, one emergency oxygen E tank that was not in use was observed left free-standing on the floor in the corner of a resident room, not secured in a sturdy portable cart. An LVN confirmed that the tank was not in use, was not secured, and had been left on the floor, and stated that E tanks should be secured in a metal portable cart for safety when not in use. The DON later stated that nursing staff should not leave E tanks on the floor in resident rooms when not in use and that staff were responsible for placing E tanks in a cart or rack for safety. In addition, surveyors observed the oxygen supplies storage room in one building and found it cluttered and unorganized, with several room air concentrators and their long electrical cords on the floor, and five E tanks stored free-standing on the floor, not secured in portable carts or metal racks. Clean and used oxygen equipment were not stored in separate areas within this room. The LVN confirmed these observations, stating that all E tanks should be placed in a metal rack or portable stand and that the room should be organized to allow safe staff access in emergencies. Review of the facility’s “Fire Safety and Prevention” policy indicated that storage rooms should be kept clean at all times, oxygen cylinders should be stored in racks with chains, sturdy portable carts, or approved stands, oxygen cylinders should never be left free-standing, and oxygen cylinders should not be stored in any resident room or living area.
Failure to Provide Timely Follow-Up Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a timely pneumococcal (PNA) vaccination to a resident in accordance with CDC recommendations and its own policy. The resident was admitted on 6/2/2021 with diagnoses including congestive heart failure, chronic kidney disease, and hypertension. Review of the resident’s immunization audit report showed that the resident had received PCV13 (Prevnar 13) on 1/13/2019. However, there was no documented evidence in the clinical record that the resident was offered or received any follow-up PNA vaccine after receiving PCV13. During an interview and concurrent review of CDC PNA vaccine recommendations with the facility’s infection preventionist (IP) on 3/3/2026 at 1:01 p.m., the IP confirmed that CDC recommends one dose of PCV20 or one dose of PCV21 at least one year after a dose of PCV13. The IP acknowledged that the facility did not offer or provide either PCV20 or PCV21 to this resident after the PCV13 dose in 2019, despite this recommendation. Review of the facility’s policy and procedure titled “Pneumococcal Vaccine,” revised March 2022, indicated that all residents are to be offered pneumococcal vaccines and assessed for eligibility prior to or upon admission and when indicated, which was not carried out for this resident.
Failure to Administer PRN Pain Medication After Resident Fall
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who exhibited clear signs and symptoms of pain following a fall. The resident, who had an active order for acetaminophen 325 mg every 4 hours as needed for mild pain, was found sitting on a floor mat in her room, moaning, groaning, unable to lift her right arm, and verbally expressing pain in her right shoulder. Despite these observations and the resident's complaints, there was no documented evidence that the as-needed pain medication was administered prior to her transfer to the hospital for further evaluation. Record review confirmed that the medication order was in place and that the resident's electronic medication administration record (EMAR) did not show administration of the pain medication after the incident. The assistant director of nursing (ADON) verified that the nurse should have provided the ordered pain management when the resident displayed symptoms and verbalized pain. Facility policy on pain assessment and management required implementation of pain management strategies based on the resident's needs, including the use of PRN medications for breakthrough pain, which was not followed in this case.
Failure to Provide Required Assistance and Person-Centered Fall Prevention
Penalty
Summary
The facility failed to provide the required level of assistance for a resident with significant cognitive and physical impairments, resulting in an unwitnessed fall and a serious injury. The resident, who had diagnoses including diabetes, muscle weakness, lack of coordination, congestive heart failure, peripheral vascular disease, and severe cognitive impairment, was assessed as needing moderate assistance for bed mobility, transfers, ambulation, and maximum assistance for toileting hygiene. Multiple therapy and nursing assessments consistently documented the resident's need for one-person physical assistance with these activities of daily living (ADLs) and identified the resident as being at moderate risk for falls. Despite these documented needs, the resident's comprehensive care plan did not include person-centered interventions specifying the required assistance for bed mobility, transfers, ambulation, toileting, and hygiene. On the date of the incident, the resident attempted to use the toilet independently without staff assistance, resulting in an unwitnessed fall in the resident's room. The fall led to a right femoral neck fracture, which required surgical intervention. Interviews with facility staff, including CNAs, LVNs, therapy staff, and the DON, confirmed that the resident required moderate to maximum assistance and that no staff were present to provide the necessary help at the time of the fall. Further review of facility policies indicated that care and services should be provided to ensure residents' ADLs do not diminish and that a resident-centered fall prevention plan should be implemented for those at risk. However, the care plan for this resident lacked documentation of person-centered interventions to address the identified risks and required assistance levels. The absence of these interventions and the lack of staff presence at the time of the fall directly contributed to the resident's injury.
Failure to Maintain Quiet, Homelike Environment Due to Noisy Metal Plates
Penalty
Summary
The facility failed to provide a resident with a room free from disruptive noise, compromising the resident's right to a safe, clean, comfortable, and homelike environment. According to a telephone interview with the resident's significant family member, persistent noise from a metal plate on the facility's driveway prevented the resident from having quiet time in their room. The family member reported that every time someone stepped on or a car passed over the metal plate, a sound could be heard from the resident's room. Observations confirmed the presence of two metal plates near the resident's room and the driveway's end, both of which produced noise when stepped on or driven over. The facility's maintenance supervisor verified that the plates were not tightly fitted to the ground, causing the noise. One plate covered the emergency water supply and could not be bolted down, while the other covered electrical wiring and belonged to an external company. The facility's policy on maintaining a homelike environment included ensuring comfortable sound levels, which was not met in this instance.
Unattended Medications Left in Resident Room
Penalty
Summary
Medications, including Zyflamend herbal pain relief, Apixaban, cod liver oil, fish oil, and progesterone, were found left unattended in a resident's room inside medication cups on a tray table next to the resident's bed. The resident, who had diagnoses of atrial fibrillation, anemia, and immunodeficiency, and a severely impaired cognition score (BIMS 5/15), was in bed at the time of observation, with no licensed staff present. The medications had been prepared and left in the room by an LVN, who confirmed that the medications were ordered by a physician and stated that the resident would take them when her son visited. Interviews with the LVN, DON, and consultant pharmacist confirmed that medications should not be left unattended in a resident's room and should be stored in locked compartments until administration. Facility policy also requires that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. The failure to secure medications as required was observed and acknowledged by staff.
Failure to Prevent Elopement Due to Inadequate Supervision and Unalarmed Exits
Penalty
Summary
A resident with severe impairment in daily decision-making skills and a diagnosis of dementia was not provided adequate supervision to prevent elopement. The resident had a history of confusion and wandering into other residents' rooms, as documented in nurse's notes and care plans. Although the care plan identified the risk for elopement and included the use of a wander guard device, it did not specify the frequency of monitoring required. The resident was able to exit the facility undetected, as the wander guard alarm did not sound due to the absence of alarms on certain exit doors along the resident's path. The resident was missing for over 15 minutes and was later found outside the facility with injuries, including a bump on the forehead, an abrasion on the knee, and a bruise on the elbow. Interviews and facility review revealed that several exit doors were not alarmed, and staff were not aware of which residents were confused or at risk for elopement. The Director of Nurses stated that more frequent monitoring was not implemented until after the elopement incident, as the resident had not previously attempted to leave. The facility's elopement policy did not provide guidance on preventive measures, and response times to alarms were observed to be delayed. The lack of adequate supervision and failure to ensure all exits were secured contributed to the resident's ability to elope and sustain injuries.
Failure to Timely Suspend Staff Following Allegations of Resident Mistreatment
Penalty
Summary
The facility failed to follow its abuse policy by not timely suspending two certified nurse assistants (CNAs) who were accused of resident mistreatment. In the first instance, a resident reported that a CNA verbally disrespected her on multiple occasions, including telling her to "shut up and mind your own business." Despite this allegation, the registered nurse who learned of the incident did not suspend the CNA as required by facility policy. In the second case, another resident reported to therapy staff that she was punched and poked on the sides of her abdomen by a CNA while being changed. When a licensed vocational nurse received this report, she changed the CNA's assignment but did not suspend the CNA. The facility's policy, revised in September 2024, states that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete. However, interviews confirmed that the required suspensions did not occur in these cases.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Deficiencies in Food Safety and Dietary Management
Penalty
Summary
The facility failed to ensure proper dietetic services systems for food safety and sanitation, exposing residents to potential contaminants and unsanitary practices. During an initial kitchen tour, several deficiencies were observed, including the lack of kitchen cleanliness monitoring, dish machine sanitizing monitoring, and recent food safety training for kitchen staff. Additionally, staff did not follow standardized recipes and therapeutic menus, and there was no emergency menu for therapeutic diets. Specific observations included a meat refrigerator without an internal thermometer, improper preparation of pureed meals without measuring ingredients, and outdated thickener used in food preparation. Further observations revealed improper food storage and preparation practices. A diet aide prepared tuna salad without chilling it to the required temperature before serving, and the staff was unaware of the correct procedures for food safety. The facility's policy required food to be prepared by methods that conserve nutritive value, flavor, and appearance, but these standards were not met. Additionally, the facility lacked a proper system for calibrating thermometers, as demonstrated by a diet aide's incorrect method of calibration. The facility also failed to maintain kitchen sanitation standards. A previous night's dinner meal was found inside a kitchen microwave, and dirty fans were observed near the food prep area. The dishwashing process was not properly monitored, with no sanitizing log maintained. Furthermore, the emergency food supply plan was incomplete, lacking a therapeutic menu for residents with special dietary needs. The facility's diet order system was also deficient, as fortified diets were not properly communicated or served to residents, despite being physician-ordered. These deficiencies highlight significant lapses in the facility's food safety and dietary management systems.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that food and nutrition services staff performed their tasks competently according to standards of practice and facility policy. A Dietary Aide did not follow the recipe for pureed salmon, resulting in a watery mixture due to incorrect measurements of water and thickener. Additionally, another Dietary Aide did not check the temperature of tuna salad before making sandwiches, failing to ensure it was chilled to the required 41°F, as per the facility's policy and FDA guidelines. The facility also did not ensure proper sanitization procedures were followed in the dishwashing process. A Dietary Aide was unable to correctly test the sanitizing step of the high-temperature dishwasher machine, as they were unaware of the proper use of Ecolab test strips. The Foodservice Director had to intervene to demonstrate the correct procedure, highlighting a lack of training and understanding among the staff regarding the sanitization process. Furthermore, a Dietary Aide failed to correctly calibrate a food thermometer, reading 34°F instead of the required 32°F. The Assistant Foodservice Director acknowledged the error and admitted that calibration was not documented on a log. This lack of proper training and documentation could lead to inaccurate temperature readings, potentially compromising food safety. These deficiencies collectively posed a risk of bacterial contamination and foodborne illnesses for the residents consuming food from the facility's kitchen.
Sanitation and Equipment Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure safe and sanitary practices in food production and storage, as evidenced by several observations. An old dinner meal plate from the previous day was found inside the kitchen microwave the following day at 11:50 a.m., indicating a lapse in routine checks by the kitchen staff. The Registered Dietitian confirmed that the meal should not have been left overnight and should have been disposed of by the staff working on Sunday night and Monday morning. Additionally, two dirty electric fans were observed in the kitchen's food preparation and clean dish areas, with one fan directly facing over the food preparation counter. The Maintenance Director stated that cleaning the fans was not part of his duties, while the Registered Dietitian noted that the janitorial environmental services department was responsible for cleaning them. Furthermore, a cracked, dented, and worn aluminum measuring cup was used to make puree meals, with the cook unable to determine the amount of water or thickener added due to unreadable measurement numbers. The Foodservice Director confirmed the condition of the measuring cup and acknowledged the need for new utensils.
Failure to Ensure Advance Directives and Complete POLST Forms
Penalty
Summary
The facility failed to ensure that three residents were informed about having an advance directive (AD) and did not have completed Physician Orders for Life-Sustaining Treatment (POLST) forms. Resident 16, admitted on 7/8/15, had no documentation of an AD, and section D of their POLST form was incomplete. The Social Service Director (SSD) confirmed the absence of an AD and stated that the facility had verbal power of attorney, but it was not reflected in the POLST form. Similarly, Resident 62's clinical record lacked documentation of an AD, and their POLST form's section D was not completed. The SSD acknowledged that the facility should have attempted to obtain and discuss the importance of a healthcare directive with the resident. Resident 84 also had no documentation of an AD, and their POLST form's section D was incomplete. The SSD confirmed the absence of an AD and stated that the facility should update the POLST form once the AD is available. The Director of Nursing (DON) confirmed that there were no advance directives for the three residents and that section D of their POLST forms was not completed. The facility's policy and procedure indicated that the social services director or designee should inquire about the existence of any written advance directives prior to or upon admission, and offer assistance in establishing them if they do not exist.
Deficiencies in Bed Rail Policy Adherence
Penalty
Summary
The facility failed to adhere to its bed rail policy for 12 out of 18 sampled residents, leading to deficiencies in the management and documentation of bed rail use. Specifically, several residents were using grab bars without the necessary physician orders or care plans. For instance, Resident 2 had grab bars installed without a physician order, despite a bed rail use evaluation recommending their use for mobility and positioning assistance. Similarly, Residents 43 and 67 were observed with grab bars in use, but there were no corresponding physician orders documented. Additionally, the facility did not have care plans in place for the use of grab bars for several residents, including Residents 8, 23, 33, and 82, even though physician orders were present. This lack of care planning was confirmed during interviews with the Director of Nursing (DON), who acknowledged the absence of care plans and stated that they should have been in place. Furthermore, Resident 70 was using grab bars without both a physician order and a care plan until these were initiated during the survey period. The report also highlights that Residents 4, 16, 20, and 51 had grab bars in use without the necessary care plans, and in some cases, without physician orders. The DON and the Minimum Data Set Director confirmed these omissions during interviews. The facility's policy on the use of side rails/bed rails emphasizes the need for these to be addressed in the resident's care plan, which was not adhered to in these cases, potentially compromising resident safety.
Failure to Follow Standardized Menus and Emergency Food Supply Procedures
Penalty
Summary
The facility failed to ensure that standardized recipes for pureed meals and menus, including the emergency food supply, were followed according to facility policy. On two separate occasions, the kitchen staff did not adhere to the pureed diet lunch menu. On the first occasion, a resident on a pureed diet was observed without pureed spinach on their plate, despite the menu indicating it should be included. The Registered Dietitian (RD) was unaware of this omission and expected the kitchen staff to follow the menus for all therapeutic diets. On the second occasion, residents on a pureed diet received pureed wheat bread instead of the garlic bread specified in the menu. The Foodservices Director (FSD) acknowledged the deviation, citing difficulty in blending garlic bread. The RD reiterated the importance of following the facility's menus to ensure residents receive accurate calories and nutrition. Additionally, the facility's emergency food supply was found lacking during a tour of the emergency supply room. The emergency binder contained a 3-day regular menu but did not include menus for residents on therapeutic diets. The FSD admitted that the emergency plan accounted for food for licensed beds and staff but not for visitors, and the emergency binder was not easily accessible. The RD and FSD recognized the importance of having an accurate emergency menu to meet the needs of residents, staff, and visitors in an emergency. The facility's policy required a written plan of action with emergency menus, but this was not adequately implemented.
Failure to Follow Standardized Puree Diet Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes for the puree diet were followed as printed, which had the potential to alter the palatability and nutritional value of the food. This deficiency was observed during a concurrent observation and interview where a cook, identified as CK K, was seen preparing pureed salmon. CK K added 5 scoops of baked salmon to a blender, followed by 2 cups of water using an aluminum measuring cup, and blended the mixture. After blending, CK K acknowledged that the salmon was very watery and added 2 scoops of thickener without knowing the exact measurements due to the lack of measurement numbers on the cup and scoop used. CK K mentioned that she would add more thickener if needed to achieve the desired consistency. The Registered Dietitian (RD) confirmed during an interview that staff should follow facility-approved recipes and measurements to ensure accurate calorie counts and nutrition. A review of the facility's job description for the cook position indicated that essential job functions include following recipes and preparing foods according to menu cycles and recipes prepared by the dietitian. Additionally, the facility's policy and procedure on food preparation emphasized the use of approved recipes standardized to meet the resident census, specifying portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. The failure to adhere to these guidelines compromised the nutritional status of twelve residents on puree diets.
Failure to Provide Physician-Ordered Fortified Diets
Penalty
Summary
The facility failed to ensure that 21 residents received their physician-ordered therapeutic diets, specifically a Fortified Diet, which is intended for residents who cannot consume adequate calories or protein to maintain their weight or nutritional status. During a lunch trayline meal service observation, it was noted that the Dietary Aide did not call out the fortified diets to the Assistant Foodservice Director, resulting in the residents not receiving the correct meals. The Registered Dietitian acknowledged this oversight and stated that the fortified food item, a scoop of cheese for the Italian lasagna entree, was not added as required. The facility's electronic health record program and tray card software program are supposed to perform monthly audits to ensure tray cards match the diet orders, but this process failed to prevent the error. The Director of Nursing stated that Licensed Nurses are responsible for checking trays against tray cards and notifying the kitchen of any discrepancies, but this protocol was not followed. The facility's policy and procedure documents indicate that each meal tray should have a tray card with the resident's diet information, and diet orders prescribed by the physician should be provided by the Food & Nutrition Services Department.
Failure to Maintain Resident Dignity During Meal Assistance and Catheter Management
Penalty
Summary
The facility failed to treat three residents with respect and dignity during meal assistance and catheter management. During a dining observation, a CNA was seen standing while assisting two residents with their meals, which is against the facility's policy that requires staff to sit while feeding residents to ensure their comfort and dignity. The CNA confirmed the observation and acknowledged the requirement to sit during meal assistance. An LVN also confirmed that staff should be seated when assisting residents with meals. The facility's policy, revised in March 2022, clearly states that residents should be fed with attention to safety, comfort, and dignity, specifically noting that staff should not stand over residents while assisting them with meals. Additionally, the facility failed to maintain the dignity of a resident with a foley catheter. The resident's urine bag was observed hanging visibly from the bedframe, which was not covered, exposing it to multiple viewing angles. The Director of Nursing confirmed that foley catheter bags should either have a dignity sleeve or a built-in cover to maintain the resident's dignity. These observations indicate a failure to adhere to the facility's standards for maintaining resident dignity and respect.
Failure to Develop Care Plan for Clopidogrel Use
Penalty
Summary
The facility failed to develop a care plan for a resident to address the use of Clopidogrel, a medication used to prevent blood clots. This deficiency was identified during a review of the resident's clinical record, which showed that the resident was admitted with diagnoses including Atherosclerotic Heart Disease and drug-induced Cushing's syndrome. Despite having a physician's order for Clopidogrel, there was no corresponding care plan to manage the medication's use. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the absence of a care plan for the resident's use of Clopidogrel. Both the ADON and DON acknowledged that a care plan should have been in place to address the medication's use and ensure appropriate interventions for the resident's treatment. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, which was not adhered to in this case.
Failure to Pause Tube Feeding During Bed Adjustment
Penalty
Summary
The facility failed to adhere to its policy and procedure for enteral tube feeding for one of the sampled residents. During an observation, a registered nurse (RN B) was seen placing a resident's head of the bed flat while the continuous tube feeding was still running. This action was contrary to the facility's policy, which requires the tube feeding to be paused when the resident's head of the bed is placed flat. The director of nursing confirmed that continuous tube feedings should be held during such care procedures. The facility's policy, last revised in November 2018, specifies that the head of the bed should be positioned at 30-45 degrees during feeding unless medically contraindicated.
Incomplete Dialysis Communication Reports for a Resident
Penalty
Summary
The facility failed to ensure that dialysis communication reports (NDCRs) were complete for a resident, identified as Resident 62, who required dialysis services. Resident 62 was admitted with diagnoses including end stage renal disease and hypertensive chronic kidney disease with stage 5 chronic kidney disease. Upon review, it was found that the NDCRs dated 11/19/24, 11/23/24, and 12/12/24 were incomplete, specifically missing the documentation of the resident's post dry weight. Licensed Vocational Nurse (LVN) H and the Director of Nursing (DON) both confirmed the incompleteness of the NDCRs during interviews and record reviews. LVN H acknowledged that the forms should be filled out completely and that any incomplete forms should be sent back to the dialysis center for completion. The DON also confirmed the missing information and stated that communication with the dialysis center should occur immediately if forms are not filled out properly. The facility's policy and procedure for the care of residents with end stage renal disease emphasized the importance of agreements with contracted ESRD facilities, including the exchange of information between facilities.
Controlled Drug Accountability Discrepancies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled drugs, leading to discrepancies between the controlled drug record (CDR) and the medication administration record (MAR) for three residents. For Resident 33, there were two instances where tramadol was signed out on the CDR but not documented on the MAR, with no evidence found in the progress notes to confirm administration. Similarly, for Resident 9, hydrocodone-acetaminophen was signed out on the CDR but not documented on the MAR, and no evidence of administration was found in the progress notes. For Resident 28, hydrocodone-acetaminophen was signed out on the CDR but not documented on the MAR, with no time recorded and no evidence of administration found in the progress notes. The facility's policy and procedures require that the date, time, and signature of the person administering the medication be recorded in the resident's medical record, which was not adhered to in these cases.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure a physician's order for a PRN psychotropic medication was limited to 14 days for a resident diagnosed with dementia, delusional disorders, and major depressive disorder. The resident was prescribed Seroquel, an antipsychotic medication, to be administered as needed for psychosis. However, the physician's order did not include a stop date, and the medication was transcribed as indefinite. This oversight led to the resident receiving the medication beyond the 14-day limitation set for PRN psychotropic medications. The Director of Nursing (DON) confirmed during an interview that PRN psychotropic medications should be limited to 14 days unless a physician provides a rationale for extending the use. The DON acknowledged that the resident's Seroquel order lacked a stop date and should have been re-evaluated after 14 days. The medication administration record showed that the resident received PRN Seroquel 23 times over three months, exceeding the 14-day limit. The facility's policy on psychotropic medication use, dated July 2022, also indicated that PRN orders should be limited to 14 days unless extended with documented rationale.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 8.82% during a survey, exceeding the acceptable threshold of 5%. This was identified through observations of medication administration for two residents. In the first instance, a registered nurse (RN C) allowed a resident to self-administer two puffs of an Arnuity Ellipta inhaler, contrary to the physician's order of one puff per day. The nurse acknowledged the error, stating that the inhaler should have been taken from the resident after the first dose. In another observation, RN B administered medications to a resident, including an oral inhaler and a nasal spray. The resident was not instructed to properly inhale and hold the medication from the inhaler, resulting in mist escaping from the mouth. Additionally, the resident was given cranberry juice instead of water to rinse the mouth, which was not in accordance with the facility's policy or the prescribing information. Furthermore, RN B administered only one spray of fluticasone nasal spray per nostril instead of the prescribed two sprays. The Director of Nursing confirmed that the facility's policy for administering inhaler medications was not followed, and the use of cranberry juice was not an acceptable substitute for rinsing with water. The errors in medication administration were verified through interviews and record reviews, highlighting a failure to adhere to prescriber orders and facility procedures, potentially compromising the residents' health.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Staff did not ensure that a dirty linen container was fully covered, resulting in soiled linens sticking out and overflowing. This was confirmed by multiple CNAs and the Director of Nursing (DON), who acknowledged that the bin should be covered to prevent the spread of infection. Additionally, the facility's policy on handling soiled laundry was not adhered to, as it requires contaminated linen to be transported and processed according to best practices for infection prevention. In another instance, a CPAP mask and hose used by a resident with obstructive sleep apnea and asthma were not properly disinfected. The mask was left exposed on a bedside table instead of being cleaned and stored in a plastic bag. This was confirmed by a CNA and the DON, who stated that the mask should be cleaned daily and allowed to air dry between uses, as per the facility's policy. Further deficiencies included unlabeled urinals in a shared bathroom, a registered nurse not changing gloves after touching non-treatment items, and a licensed vocational nurse not using the appropriate disinfectant for a glucometer between uses. These actions were confirmed by staff interviews and were contrary to the facility's policies on labeling personal items, hand hygiene, and equipment disinfection, potentially compromising resident health and safety.
Unsafe Coffee Machine Maintenance
Penalty
Summary
The facility failed to maintain a coffee machine in a safe and operable condition according to the manufacturer's guidelines and facility policy. During observations of the lunch trayline meal service on December 16 and 17, 2024, a Diet Aide was seen preparing coffee for resident meals using a coffee machine that had three missing buttons, exposed electrical wires, and a door secured with a clear strip of tape. The Foodservices Director confirmed these issues and stated that the facility had been on a waitlist to receive a new coffee machine from the vendor for several months. The Registered Dietitian indicated that the broken buttons of the coffee machine had been included in the Quality Assurance and Performance Improvement Plan since October 28, 2024, due to the safety issues they posed for kitchen staff. The facility's policy on sanitation, dated 2023, requires that all equipment be maintained in good repair and free from breaks, corrosion, open seams, cracks, and chipped areas. The failure to adhere to this policy had the potential to impact the dietary staff's ability to prepare and serve coffee in a safe and sanitary manner.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident. Specifically, seven rooms (Rooms 150, 151, 152, 153, 156, 160, and 163) were found to be below this standard, with some rooms measuring only 71.5 square feet per resident. Despite this deficiency, observations during the survey indicated that nursing care and services were not impacted by the limited space, as both residents and staff were able to move freely within the rooms. Additionally, neither the residents nor the staff expressed concerns regarding the room sizes.
Failure to Ensure Safe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards during the transfer of a resident, leading to a fall and subsequent hospitalization. The resident, who had a history of hemiplegia, hemiparesis, aphasia, and other mobility issues, was not evaluated for fall risk upon admission. This oversight was confirmed by both the Director of Nursing and the Minimum Data Set Coordinator, who acknowledged that the fall risk evaluation should have been completed as part of the admission process. During the transfer incident, a certified nursing assistant (CNA) and a registered occupational therapist (ROT) attempted to move the resident using a Hoyer lift. However, the CNA did not follow the user manual instructions, failing to check the suitability and size of the sling used for the resident. The sling was not the appropriate full-body type recommended for the resident, and no one supported the sling during the transfer. As a result, the resident slipped through the sling and fell, sustaining a small intracranial hemorrhage. Interviews with staff revealed that the CNA had requested assistance for the transfer but proceeded without adequate help due to a lack of available staff. The ROT, who assisted, did not observe the fall but noted that the resident likely slipped through the bottom of the sling. The facility's training materials and policies emphasized the importance of using the correct sling size and supporting the resident during transfers, but these protocols were not followed, contributing to the accident.
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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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