Torrance Care Center West, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 4333 Torrance Blvd, Torrance, California 90503
- CMS Provider Number
- 055952
- Inspections on file
- 37
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Torrance Care Center West, Inc during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, moderately impaired cognition, tremors, and need for substantial/maximal ADL assistance required supervision or touch assistance with eating. A CNA placed the resident’s lunch tray, including a cup of hot water, on an overbed table positioned over the resident’s legs and then left to assist the roommate, leaving the hot liquid within the resident’s reach and unattended. The cup of hot water fell onto the resident’s right leg, causing a second-degree thermal burn with erythema and peeling skin. An LVN and podiatrist confirmed the burn characteristics, and the DON acknowledged the resident’s limited fine motor skills and that the tray with hot items should not have been left unattended, contrary to the facility’s accidents and supervision policy.
A resident with Parkinson’s disease and moderately impaired cognition sustained a second-degree burn to the right leg when hot liquid spilled from a cup placed on an overbed table. Nursing documentation misidentified the burn location as the right forearm. An LVN acknowledged not notifying the resident’s Responsible Party (RP) and stated he only endorsed the injury to an unidentified charge nurse, while an RN confirmed she knew of the injury but did not notify the RP. The RP later learned of the injury independently and expressed frustration. This sequence of events shows the facility did not follow its policy requiring the nurse supervisor/charge nurse to notify the family/representative after any accident or incident resulting in injury.
A resident with Parkinson’s disease and moderately impaired cognition sustained a thermal burn from spilled hot tea. An LVN documented the injury in a nursing note as a partial thickness burn on the resident’s right forearm, although the burn was actually on the right lateral leg. Later, a COC note documented a burn to the right lateral leg from the same hot tea incident but with a different date, creating the appearance of two separate burn injuries. The DON determined that this conflicted with facility policy requiring accurate, care-specific documentation of procedures, treatments, and assessment data.
A resident with multiple diagnoses and intact cognition did not consistently receive meals according to their documented vegetarian dietary preferences, despite submitting dietary request forms and having a physician order specifying allowable foods. The facility failed to update and document changes to the resident's food preferences in the care plan, resulting in repeated delivery of meals that did not honor the resident's requests.
A resident with specific dietary needs and preferences did not consistently receive meals in accordance with his physician-ordered vegetarian diet, as dietary requests were not always fulfilled and changes in preferences were not documented or communicated among staff. This resulted in the resident receiving non-preferred meals, including those containing meat, despite facility policy requiring documentation and honoring of food preferences.
A resident with significant care needs was not informed about the grievance process and her ongoing complaint regarding improper brief changes was not documented or addressed according to facility policy. The Social Service Director and DON acknowledged that the resident and her family were not provided with information on how to file a grievance, and the complaint was not entered into the grievance log as required.
A resident with significant physical disabilities experienced ongoing discomfort and embarrassment due to improper fitting of an adult brief, as the facility failed to create and implement a person-centered care plan with specific, measurable interventions for proper brief adjustment. Staff and care plan documentation confirmed the absence of individualized strategies to address the resident's repeated complaints and needs.
Residents were not given reasonable access to communication methods or privacy when using them, as observed and documented by surveyors.
Several residents with severe cognitive impairment and lacking decision-making capacity had advance directive forms that were either unsigned or improperly signed by facility staff rather than a legally authorized representative. Staff interviews and record reviews confirmed that responsible parties were not involved as required, and the facility did not consistently provide or document advance directive discussions or written information for these residents.
Licensed staff were unable to accurately describe or follow procedures for securing emergency medication kits, and annual performance evaluations for several staff members were not completed as required by facility policy. These deficiencies were identified through interviews and record reviews, revealing gaps in staff competency and adherence to established protocols.
A resident with PTSD, depression, and anxiety did not receive a psychologist consultation as ordered and requested, due to the Social Services Director failing to arrange the appointment or document the request. The resident's care plan and physician order called for a psychology consult, but the necessary follow-up was not completed, resulting in the resident not receiving appropriate mental health services.
A resident with schizoaffective disorder and other mental health conditions was found to have Zyprexa 5 mg and 10 mg tablets mixed in the same plastic bag, labeled only for the 5 mg dose. During a medication pass, an LVN administered the 5 mg dose and later confirmed that the medications should have been stored separately. The DON also acknowledged the error, noting that facility policy requires segregation and proper labeling of medications.
Surveyors found that opened medication bottles for multiple residents, including those containing Valproic Acid, Constulose, Megestrol, and Enulose, were not labeled with the date they were opened. An LVN confirmed that all medications should be labeled upon opening, and the DON stated that the facility's procedure is to label medications when opened, but this was not followed, resulting in medications without open date labels in the medication cart.
Surveyors found that food items such as milk and chips were not labeled with open dates, expired celery and hotdog buns were not discarded, and chicken was improperly thawed in standing water. Additionally, the kitchen's sanitation bucket contained insufficient quaternary ammonium sanitizer, all of which were acknowledged by dietary staff as not meeting required standards.
Three residents were presented with incomplete arbitration agreements, with two cognitively impaired residents asked to sign without proper assessment of their capacity or involvement of a representative. Facility staff confirmed that the agreements were invalid and not explained as required by policy.
The facility experienced repeat deficiencies in areas such as resident rights, advance directives, Medicare coverage notification, transfer notice requirements, assessment accuracy, care plan implementation, social services, pharmacy services, medication storage, and infection control due to the QAA committee's failure to provide effective oversight and implement corrective actions from the previous survey.
Staff failed to follow infection control protocols, including not disinfecting a medication tray between residents, improper handling of soiled linens by a CNA, and allowing a resident to access clean linen carts without staff assistance. These actions were not in accordance with facility policies and were confirmed by staff interviews and record reviews.
Twenty rooms were found to have less than the required 80 sq. ft. per resident in multiple occupancy bedrooms. Although residents could move about and there was space for necessary equipment, the Administrator confirmed the rooms did not meet the minimum size standard and had requested a waiver, stating that resident movement and safety were not compromised.
A resident with cognitive and physical care needs was found to have their call light on the floor and out of reach, preventing them from requesting staff assistance. Staff interviews confirmed that ensuring call light accessibility is a shared responsibility and a facility policy, but this was not followed, resulting in a deficiency related to resident rights and safety.
Residents were not fully informed about their health status, care, and treatments. The facility did not provide adequate communication to ensure that residents understood their medical conditions and the care or treatments being administered.
A resident with cognitive deficits and limited English proficiency was unable to access her pictogram communication board, which staff had placed inside a bedside drawer out of reach. Staff and policy confirmed the board should always be accessible, as it is the resident's primary means of communication for expressing needs and preferences.
A resident with severe cognitive impairment and multiple diagnoses did not receive appropriate notification of Medicare coverage changes, as the NOMNC form was given directly to the resident without involving a responsible party or legal representative. Staff acknowledged the resident was unable to understand the information and that guardianship should have been pursued, but this was not done, resulting in failure to follow required notification procedures.
The facility did not provide a written bed hold notice or timely Ombudsman notification for a resident transferred to a hospital, instead relying on outdated documentation and delayed communication. Additionally, another resident who requested assistance with discharge to assisted living did not receive help from the Social Services Director, despite being medically stable and having expressed her wishes weeks earlier. These actions were not in accordance with facility policy and resulted in incomplete documentation and lack of support for residents' needs.
Two residents did not receive appropriate care plan interventions: one with a seizure disorder did not have padded side rails as specified in the care plan, and another with a sacrococcyx wound did not have a care plan developed for wound care. Staff interviews and record reviews confirmed these omissions, despite facility policy requiring comprehensive, individualized care plans.
A nurse administered an over-the-counter cough medication to a resident with multiple chronic conditions and moderate cognitive impairment without obtaining a physician's order. The nurse believed a physician's order was not required for over-the-counter medications, but facility policy and the DON confirmed that all medications must be ordered by a physician.
Two residents dependent on staff for ADLs did not receive necessary oral care and fingernail hygiene. One resident was observed with dry lips and a crusty film around the mouth, while another had long, dirty fingernails and was seen eating with them. Staff interviews confirmed that required hygiene care was not consistently provided or communicated, despite facility policies mandating such care.
A resident with severe cognitive impairment and impaired vision was left without reading glasses after his previous pair broke. Despite staff being informed of the need for replacement glasses, no action was taken to provide them, leaving the resident without necessary adaptive equipment as required by facility policy.
A resident with severe cognitive impairment and multiple chronic conditions was found to have oxygen tubing in use without a start or change date label. An LVN confirmed that the tubing was supposed to be changed weekly and labeled, but this was not done, contrary to facility policy.
Two residents with PTSD were not properly assessed for their condition or triggers, and staff—including the SSD, CNAs, and LVNs—were unaware of these diagnoses and did not provide individualized interventions. The facility lacked documentation and care planning for PTSD, despite policy and job description requirements for comprehensive behavioral health assessments and interventions.
The facility did not provide the medically-related social services needed for a resident to achieve the highest possible quality of life, resulting in unmet social and emotional needs.
A CNA left a binder containing confidential ADL documentation open and unattended near a resident's room, and a physician's telephone order for wound care was not transcribed accurately, omitting instructions for a dry dressing. These actions resulted in failures to protect resident information and maintain accurate medical records, as confirmed by staff interviews and facility policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents received blood pressure-lowering medications despite their blood pressure readings being below the physician's specified parameters. The facility's Director of Nursing confirmed that multiple LVNs failed to follow the orders, resulting in significant medication errors. The facility's policy required checking blood pressure before administering medication and holding it if readings were outside the parameters.
The facility failed to follow physician-ordered parameters for administering blood pressure medications to two residents, leading to significant medication errors. Despite specific instructions to hold medications if blood pressure or heart rate fell below certain levels, medications were administered when readings were below these thresholds. The DON confirmed that the facility's policy required checking vital signs before medication administration and holding medications if readings were outside the parameters.
A resident assessed as high risk for falls was not provided with safe transfer assistance, leading to a fall. The CNA did not use a gait belt or follow the facility's procedure requiring two-person assistance. The resident's Care Plan lacked specific interventions for safe transfers, and staff interviews revealed inconsistencies in following transfer protocols. The facility's policies on fall prevention and gait belt use were not adhered to, placing the resident at risk for injury.
A resident with anxiety disorder and nicotine dependence reported that a CNA lit a butane lighter close to their face, causing fear of burns. Despite the complaint to the Administrator, no investigation was documented. The Administrator admitted the oversight, focusing instead on another abuse allegation. This failure to investigate violated the resident's right to voice grievances without reprisal.
A resident with epilepsy and movement disorders fell and sustained an injury, but the LTC facility failed to update the care plan with new interventions despite the resident being identified as a high fall risk. The DON acknowledged the oversight, which was against the facility's policies on care planning and fall prevention.
The facility failed to ensure a safe environment for five residents who were smokers by not securing smoking materials and not providing adequate supervision. Residents were found with cigarettes and lighters, and some were observed smoking without staff supervision, despite being identified as unsafe smokers. This lack of adherence to policy posed a significant risk of fire and injury.
The facility did not employ a qualified full-time Social Worker as required for facilities with over 120 beds. The Social Service Director (SSD) worked part-time in the role while also serving as a CNA, failing to meet the full-time hours needed. Despite the Director of Staff Development informing the Administrator of this issue, no corrective action was taken. The facility's job description confirmed the necessity for a full-time Social Worker to meet residents' needs.
The facility's QAA and QAPI committee failed to employ a full-time qualified social worker, as required for facilities with over 120 residents, and did not address this issue in QAPI meetings. Additionally, the facility lacked adequate supervision for unsafe smokers and did not develop a policy for checking smoking paraphernalia, despite the potential risk to residents' safety.
A resident with mental health and chronic kidney conditions was observed walking without proper footwear in a facility, compromising their dignity. Staff interviews confirmed the oversight, acknowledging the importance of shoes for the resident's dignity and safety. The facility's policy on maintaining resident dignity was not upheld.
A resident's POLST form was found incomplete during a review, despite the facility's policy requiring careful decision-making and regular reviews. The resident, with conditions like major depressive disorder and pancreatitis, had the capacity to make decisions, but the form was not fully completed, potentially affecting their treatment preferences in emergencies.
A facility failed to notify a resident about changes in their Medicare coverage by not providing a signed Notice of Medicare Non-Coverage (NOMNC) form. The resident, with severe cognitive impairment and requiring assistance for daily activities, was not informed of the appeal process due to the oversight of the Social Service Director. The facility's policy required the NOMNC to be issued when Medicare services end, with specific procedures for notification if hand delivery was not possible.
A resident with intact cognition and multiple diagnoses was inappropriately assessed and transferred due to the facility's failure to implement behavioral interventions. Despite expressing a desire to contact her son, staff did not document any efforts to facilitate this communication. The DON noted insufficient documentation and lack of clarity on whether the resident's son was contacted, which could have addressed the resident's needs.
A facility failed to send the Notice of Proposed Transfer/Discharge form to the State Long-Term Ombudsman for a resident transferred to a hospital. The resident, with intact cognition and multiple diagnoses, was not properly documented in the facility's records. Interviews revealed that the facility's process of faxing transfer forms to the Ombudsman was not followed, as confirmed by the Social Worker and Administrator.
A facility failed to correctly encode a resident's discharge status on the MDS, marking it as a hospital transfer instead of a discharge to home or community. The resident had diagnoses including Type 2 diabetes, hypothyroidism, and hypertensive heart disease. The error was identified by the MDS nurse, who noted that incorrect coding could disrupt continuity of care and affect CMS quality measures.
A resident did not receive a complete dental assessment upon admission, as required by the facility's policy. The assessment lacked verification of the resident's ability to function without dentures and their desire for dentures, potentially affecting their nutrition. The resident had a history of major depressive disorder, schizoaffective disorder, and oropharyngeal dysphagia, which could impact decision-making and nutritional intake.
A facility failed to complete a PASARR Level II Screening for a resident with suspected mental illness, as required by their PASARR Level I Screening. The resident, diagnosed with schizophrenia and schizoaffective bipolar disorder, did not receive the necessary evaluation before admission. The DON confirmed that the admitting RN was responsible for ensuring the completion of such screenings.
The facility failed to create individualized care plans for three residents, including one with bed rails, a smoker, and another who refused dental services. This lack of care plans left staff without guidance on managing these residents' specific needs, contrary to facility policies.
A resident with schizoaffective disorder and chronic kidney disease, who required assistance with daily activities, was at risk for falls due to not wearing shoes. Despite being redirectable, the care plan was not updated to include reminders for wearing shoes, as acknowledged by both an LVN and the DON.
Burn Injury from Unsupervised Hot Liquid Near Resident with Parkinson’s Disease
Penalty
Summary
The deficiency involves the facility’s failure to prevent an avoidable burn injury to a resident with Parkinson’s disease by not adequately considering his functional limitations and by leaving hot liquid within his reach and unattended. The resident was admitted with Parkinson’s disease and had moderately impaired cognition. His MDS assessment indicated he required substantial/maximal assistance with ADLs and supervision or touch assistance with eating. Staff were therefore aware that he had tremors, poor coordination, impaired mobility, and could not independently bring a utensil or cup to his mouth. On the day of the incident, CNA 1 placed the resident’s lunch tray, which included a cup of hot water, on the overbed table and positioned the table halfway over the resident’s legs near his knees. CNA 1 then left the resident unattended and went to assist the roommate with his lunch tray. While CNA 1 was assisting the roommate, she saw the cup of hot water falling from the resident’s tray and attempted, unsuccessfully, to catch it before it spilled onto the resident. CNA 1 later acknowledged that the resident experienced frequent shaking in his upper extremities, required a lot of assistance when eating, and that she should not have placed the tray with hot water so close to him because he could have grabbed the cup and caused it to fall. Following the spill, LVN 1 observed a wet, warm blanket over the resident’s legs, a cup on top of the blanket, and a fresh red wound with peeling skin on the resident’s right leg. Nursing documentation and a change of condition note described a thermal burn with erythema and superficial skin peeling consistent with a partial-thickness burn to the right lateral leg, and a podiatrist later classified the injury as a second-degree burn involving the epidermis and dermal layers. The DON stated that the resident’s fine motor skills were limited and that his lunch tray with hot items should not have been left unattended. The facility’s accidents and supervision policy required staff to observe and identify potential hazards in the environment while considering each resident’s unique characteristics and abilities, which was not followed in this case.
Failure to Notify Responsible Party of Resident Burn Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Responsible Party (RP) of a burn injury in accordance with its policy on changes in a resident’s condition or status. The resident, who had Parkinson’s disease and moderately impaired cognition per the MDS dated 1/21/2026, sustained a thermal burn when a cup containing hot liquid was placed on the overbed table and spilled onto the resident’s right lateral leg, causing a second-degree, partial-thickness burn with erythema and superficial skin peeling. The nursing note dated 12/28/2025 documented the injury but incorrectly described the burn as being on the right forearm instead of the right leg. Following the incident, LVN 1 stated he did not notify the resident’s RP about the burn injury and claimed he had endorsed the resident’s injury status to an unidentified charge nurse on the 3 p.m. to 11 p.m. shift. RN 1 acknowledged that LVN 1 reported the burn injury to her but stated she was unaware that the RP had not been notified and confirmed that she also did not notify the RP. The Administrator later reported that the RP called on 1/5/2026, expressing frustration at not having been informed of the burn injury that occurred on 12/28/2025. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” dated 4/2011 showed that the Nurse Supervisor/Charge Nurse is required to notify the resident’s family or representative when the resident is involved in any accident or incident resulting in injury, including injuries of unknown source, which did not occur in this case.
Inaccurate Documentation of Resident Burn Location and Date
Penalty
Summary
The deficiency involves inaccurate clinical documentation related to a resident who sustained a thermal burn. The resident, admitted with Parkinson’s disease and assessed as having moderately impaired cognition, experienced a burn injury from an accidental spill of hot tea. A nursing note dated 12/28/2025 documented the burn as being on the resident’s right forearm, describing erythema and superficial skin peeling consistent with a partial thickness burn. This documentation was incorrect, as the injury actually involved the resident’s right lateral leg. A subsequent Change of Condition (COC) note dated 1/13/2026 documented a thermal burn to the resident’s right lateral leg from an accidental hot tea spill, which was the same injury but recorded with a different body location and date. During interview, the LVN who wrote the original note stated that an audit identified his error in documenting the burn location and that he was instructed to correct the documentation. He reported being unable to change the original COC note, which had been initially dated 12/28/2025, and instead created a new COC note dated 1/13/2026. The DON, after reviewing both entries, stated that this documentation made it appear as if the resident had two different burn injuries. The facility’s charting and documentation policy required care-specific details, including accurate date, time, and assessment data, which were not met in this case.
Failure to Develop and Implement Person-Centered Care Plan for Dietary Preferences
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that honored a resident's food preferences, resulting in the resident expressing dissatisfaction with meals that did not align with his dietary requests. The resident, who had diagnoses including COPD, anxiety disorder, and PTSD, was cognitively intact and able to independently manage most activities of daily living. Despite having a physician order specifying a vegetarian diet with certain allowable foods and completing dietary request forms, the resident did not consistently receive meals according to his preferences. On multiple occasions, the resident was served items not permitted by his diet, such as shredded chicken and meat patties, and was told by kitchen staff that requested items were unavailable. Interviews and record reviews revealed that while the resident's food preferences were assessed upon admission and communicated verbally to the kitchen, there was no documentation of updates to the resident's Nutrition/Dietary Food Preference since admission. The Dietary Technician acknowledged the importance of documenting changes but confirmed that updates were not made, leading to confusion and unmet meal requests. The resident's care plan did not include goals or interventions addressing changes in food preferences, and the facility's policy required care plans to be dynamic and person-centered, incorporating resident choices and preferences. The lack of documentation and care plan updates resulted in inconsistent care and unmet resident needs.
Failure to Honor and Document Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were honored, resulting in the resident not consistently receiving meals in accordance with his dietary plan. The resident, who had diagnoses including COPD, anxiety disorder, and PTSD, was assessed as having intact cognition and was independent in eating. Despite having a physician order specifying a vegetarian diet with certain allowed breakfast items, the resident reported receiving meals inconsistent with his preferences on multiple occasions. He completed dietary request forms, but on at least two occasions, his requests were not fulfilled due to unavailability of requested items, and he subsequently stopped submitting requests. The resident also reported receiving meals containing meat, which was not in line with his dietary restrictions, even after discussing his meal plan with facility staff. Interviews with dietary staff revealed that while food preferences were assessed upon admission and intended to be updated as needed, there was no documentation of updates to the resident's food preferences since admission. Staff acknowledged the importance of documenting changes to ensure all team members were informed and to maintain consistency in meal preparation. The facility's policy required honoring and documenting individual food preferences, but the lack of documentation and communication led to the resident not receiving his preferred meals.
Failure to Inform Resident of Grievance Process and Address Complaint
Penalty
Summary
The facility failed to provide a resident with information on how to file a grievance and did not follow its own grievance policy and procedures. The resident, who had a history of cerebral infarction, hemiplegia, and a left above-the-knee amputation, required significant assistance with activities of daily living. During an interview and observation, the resident reported ongoing discomfort and irritation due to improper application of her adult brief, an issue she stated had persisted since admission. She also reported that some staff displayed negative attitudes when she requested assistance and that her complaints about the issue were not addressed. The Social Service Director (SSD) acknowledged awareness of the resident's complaint but did not document it in the grievance log or provide the resident or her family with information on how to file a grievance. The SSD admitted that she should have informed the resident about the grievance process and formally addressed the complaint. The Director of Nursing confirmed that residents should be informed about the grievance process, especially when there is an ongoing complaint. Review of facility policies indicated that staff are required to respond promptly to complaints and that the SSD is responsible for assisting residents in voicing and resolving grievances, but these procedures were not followed in this case.
Failure to Develop and Implement Individualized Care Plan for Adult Brief Adjustment
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan with measurable objectives and interventions to address a resident's needs regarding the adjustment and fitting of an adult brief. The resident, who had a history of cerebral infarction, hemiplegia, and left above-knee amputation, required significant assistance with mobility and personal care. Despite repeated complaints from the resident about discomfort, embarrassment, and avoidance of activities due to improper fitting and leakage of the adult brief, the care plan did not include specific interventions to address these concerns. Observations and interviews revealed that the resident's adult brief was often applied incorrectly, resulting in wet clothing and discomfort. Staff, including a CNA and the DON, acknowledged the ongoing issue and the lack of detailed instructions or interventions in the care plan for proper adjustment of the brief. The resident expressed frustration with staff not following her instructions and reported that her complaints had not been addressed since admission. A review of the care plan and interdisciplinary team meeting notes confirmed that the interventions were generic and did not address the resident's specific needs for adult brief adjustment. The care plan focused on managing aggressive behavior during diaper changes but did not provide objective, measurable goals or resident-centered strategies for ensuring proper brief application. Facility policies required comprehensive, person-centered care plans, but these were not followed in this case.
Failure to Ensure Resident Privacy and Access in Communication
Penalty
Summary
Residents were not provided with reasonable access to communication methods or afforded privacy when using them. The facility failed to ensure that residents could use telephones or other means of communication in a manner that protected their privacy. This lack of access and privacy was directly observed and documented by surveyors during the review.
Failure to Properly Execute Advance Directives for Residents Lacking Capacity
Penalty
Summary
The facility failed to ensure that advance directive forms were properly executed by residents or their legally authorized representatives for six residents with severe cognitive impairment. In multiple cases, residents with diagnoses such as dementia, schizoaffective disorder, and other mental health conditions were found to lack the capacity to make informed decisions, as documented in their medical records, Minimum Data Set (MDS) assessments, and History and Physical (H&P) notes. Despite this, advance directive forms were either left unsigned by the resident or, in some instances, were signed by the facility's social worker instead of the resident or a legally authorized representative. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the process for obtaining and documenting advance directives was not followed appropriately. Staff acknowledged that residents with severe cognitive impairment should not have been asked to sign these forms and that responsible parties or legal representatives should have been involved. In some cases, the facility did not reoffer the advance directive after admission, and there was no evidence that public guardianship was pursued for residents unable to make decisions and without family involvement. The facility's policies and job descriptions require that residents or their representatives be provided with written information about advance directives and that the process be overseen by the Social Services Director. However, documentation and interviews revealed that these requirements were not met, resulting in incomplete or improperly executed advance directive forms for residents who lacked decision-making capacity.
Failure to Ensure Staff Competency in Emergency Kit Handling and Annual Evaluations
Penalty
Summary
The facility failed to ensure that licensed staff were competent in following facility policies and procedures regarding the handling and securing of emergency medication kits (E-Kits). During interviews and observations, two licensed staff members were unable to accurately describe the process for securing E-Kits after use. One registered nurse supervisor stated she had not received in-service training on E-Kits and could not explain the securing process, while a licensed vocational nurse provided an incorrect description of the procedure. The facility's policy requires specific steps for documenting, reporting, and securing E-Kits, which were not followed or understood by the staff involved. Additionally, the facility did not complete or document annual performance evaluations for five staff members as required by facility policy and regulatory standards. The Director of Staff Development acknowledged that these evaluations were not performed due to workload, and the Director of Nursing confirmed that the absence of evaluations meant staff competencies and areas needing improvement were not formally assessed. The facility's policy mandates yearly written evaluations to review employee performance, but this process was not carried out for the identified staff.
Failure to Arrange Psychologist Consultation for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and anxiety received a psychologist consultation as requested by the resident and ordered by the physician. The resident's care plan included interventions such as medication management, encouragement to verbalize feelings, and a psychology consultation as needed. Despite a standing order for a psychologist consult and the resident's direct request to the Social Services Director (SSD), no appointment was made, and the request was not documented. The SSD assumed that the standing order was sufficient and did not follow up or arrange the necessary consultation. Interviews revealed that the resident specifically asked to see a psychologist, but the SSD did not act on this request or document the conversation. The Director of Nursing (DON) confirmed that the SSD should have scheduled the appointment and documented the resident's request. Facility policy and the SSD job description both require the provision and documentation of medically related social services, including arranging for mental health counseling when needed. This lapse resulted in the resident not receiving the proper assessment and necessary treatment for his PTSD.
Improper Storage and Labeling of Zyprexa Doses
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for a resident with multiple mental health diagnoses, including unspecified psychosis, major depressive disorder, and schizoaffective disorder, bipolar type. During a medication pass observation, it was found that Zyprexa 5 mg and Zyprexa 10 mg tablets were mixed together in the same plastic bag, which was labeled only for the 5 mg dose. The medication administration record indicated that the resident was prescribed Zyprexa 5 mg in the morning and Zyprexa 10 mg in the evening, with each dose intended to be administered separately. The licensed vocational nurse (LVN) administering the medication was unaware of who had placed both doses in the same bag and acknowledged that the medications should have been stored separately. Interviews with the LVN and the Director of Nursing (DON) confirmed that the practice of mixing different doses of Zyprexa in one bag was improper and could lead to medication errors. The DON reviewed a photograph of the mixed medications and stated that the medications should have been separated, with the 10 mg dose stored in the medication cart for evening administration. The facility's policy and procedure on medication storage required segregation and proper labeling of medications, which was not followed in this instance.
Failure to Label Opened Medications with Date Opened
Penalty
Summary
Surveyors observed that opened medication bottles for eight residents were not labeled with the date they were opened. During an inspection of the morning medication cart in building B, several medications, including Valproic Acid, Constulose, Megestrol, and Enulose, were found without open date labels. This was confirmed during an interview with an LVN, who acknowledged that all medications should be labeled with the date they are opened. The LVN also stated that failing to label medications with open dates could affect the medications' effectiveness for residents. Further interview with the DON revealed that the facility's practice was to place open date labels on medication bottles upon opening and then return them to the medication cart. However, the medications observed did not have these labels, indicating a lapse in following this procedure. The DON confirmed that the absence of open date labels could result in decreased effectiveness of the medications for residents.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and sanitation practices. An open gallon of milk and a bag of potato chips in the kitchen were found without open date labels. Additionally, a bin of celery and several bags of hotdog buns were observed to be past their expiration dates. Two tubs of chicken were seen thawing in standing water in the sink, rather than under cold running water as required. Dietary staff confirmed that all opened food items should be labeled with an open date, expired food should be discarded, and chicken should be thawed under running cold water to prevent foodborne illness. Further, the sanitation bucket used in the kitchen was found to contain only 10 parts per million (ppm) of quaternary ammonium sanitizer, which is below the required concentration. The dietary supervisor and dietary aides acknowledged that the sanitizer solution should be maintained at 200-400 ppm to ensure proper sanitation and prevent cross contamination. Review of facility policies confirmed the need for proper food labeling, storage, and sanitation practices, as well as adherence to FDA food code standards for food preparation and thawing.
Failure to Properly Complete and Explain Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were accurately completed and that residents or their representatives were properly informed of their rights regarding these agreements. Specifically, three residents were affected: one resident with intact cognition had an incomplete arbitration agreement lacking a facility staff signature, while two other residents with moderate to severe cognitive impairment had incomplete arbitration agreements with missing resident or representative signatures. The facility did not assess the mental capacity of these residents or provide them with adequate information before presenting the arbitration agreements for signature. Interviews with facility staff confirmed that residents with impaired cognition should not have been asked to sign arbitration agreements, and that the agreements for all three residents were incomplete and therefore invalid. The facility's policy required that arbitration agreements be explained in a manner understandable to the resident or their representative, and that the resident acknowledge understanding of the agreement. These requirements were not met for the sampled residents, as evidenced by incomplete documentation and lack of proper assessment of decision-making capacity.
Repeat Deficiencies Due to Ineffective QAA Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and did not implement the plan of correction for deficiencies identified during the previous recertification survey. This lack of oversight resulted in repeat deficiencies in several critical areas, including resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementation of care plans, social services, pharmacy services, medication storage, and infection control and prevention. The administrator acknowledged during an interview that there were repeat deficiencies and indicated that the facility's audits and chart reviews by social workers were not sufficiently robust. A review of the facility's Quality Assurance and Performance Improvement (QAPI) policy revealed that the committee is responsible for developing and implementing plans of action to correct identified quality deficiencies. However, the report indicates that the QAA committee did not fulfill these responsibilities, as evidenced by the recurrence of the same deficiencies from the previous survey. There is no mention of specific residents or their medical conditions in relation to these deficiencies.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices in several instances involving multiple residents. During a medication pass, a Licensed Vocational Nurse used a medication tray for one resident without disinfecting it before using it for another resident. The nurse acknowledged that the tray was not sanitized between uses, which is contrary to facility policy and infection control standards. The resident involved had diagnoses including paranoid schizophrenia and bipolar disorder and required assistance with daily activities. In another incident, a Certified Nursing Assistant handled a soiled gown from a resident with dementia, schizophrenia, and COPD by holding it close to his body and transporting it through the facility without placing it in a plastic bag or laundry barrel as required. The CNA admitted there was no plastic bag or laundry barrel available at the time and recognized that dirty linens should be kept away from staff clothing to prevent the spread of infection. The Infection Preventionist Nurse and Director of Nursing both confirmed that this practice could lead to cross contamination and was not in line with facility policy. Additionally, a resident was observed taking clean linen from a linen cart in the hallway without staff assistance. Staff interviews confirmed that residents should not access clean linen carts on their own, as this could result in cross contamination. Facility policy specifies that access to clean storage areas should be limited to staff only. These observed failures in infection control practices were confirmed through interviews and record reviews.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 20 out of 78 rooms, as required. During a facility tour, it was observed that residents in the affected rooms were able to move in and out of their rooms, and there was space for beds, side tables, and resident care equipment. However, a review of room measurements confirmed that these rooms did not meet the minimum square footage requirement. The Administrator acknowledged that these rooms were below the required size and had submitted a waiver request, stating that there was adequate space for resident movement and that the room sizes did not adversely affect residents' health and safety. The specific rooms identified each had three beds but provided less than the required 240 square feet per room.
Call Light Inaccessibility Compromises Resident Rights and Safety
Penalty
Summary
A deficiency was identified when a resident's call light, an essential communication tool for requesting staff assistance, was found on the floor behind the resident's bed and not within reach. The resident, who had diagnoses including schizoaffective disorder, major depressive disorder, and failure to thrive, was documented as having a fluctuating capacity to understand and make decisions and required supervision or touching assistance for activities such as toileting hygiene, showering, and personal hygiene. During an observation and interview, a CNA confirmed that the call light was not accessible to the resident and acknowledged responsibility for ensuring call lights are within reach. The CNA also stated that the resident would not be able to pick up the call light from the floor independently and relies on it for assistance. Further interviews with an LVN and the DON confirmed that facility policy requires all staff to ensure call lights are always accessible to residents before leaving the room. Both staff members reiterated that the resident depends on the call light for help and that its inaccessibility creates a safety risk. Review of facility policies supported the expectation that call lights be positioned for easy access and that resident dignity and rights be maintained. The failure to ensure the call light was within reach compromised the resident's ability to request assistance and did not align with facility policy or resident rights.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not consistently receive explanations or updates about their health status or the treatments they were receiving.
Failure to Provide Accessible Communication Board for Non-English Speaking Resident
Penalty
Summary
Staff failed to ensure reasonable accommodation of a resident's communication needs by not making the resident's pictogram communication board accessible. The resident, who only speaks Korean and has diagnoses including schizoaffective disorder, major depressive disorder, and failure to thrive, relies on the pictogram as her primary means of communication due to cognitive deficits and fluctuating capacity to understand and make decisions. During observation and interviews, it was found that the pictogram was kept inside the bedside table drawer, out of the resident's reach, contrary to the care plan intervention which specified that the communication board should be provided if applicable. Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) interviews confirmed that the pictogram was not accessible and that staff rely on it to understand the resident's needs. The facility's Director of Nursing (DON) and policy documents also indicated that communication devices must always be kept within reach to allow residents to express their needs, preferences, and concerns. The failure to keep the pictogram accessible was a direct violation of the facility's policy and the resident's care plan, impeding the resident's ability to communicate effectively.
Failure to Provide Proper Medicare Non-Coverage Notice to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was appropriately notified regarding changes in their Medicare coverage through the provision of the Notice of Medicare Non-Coverage (NOMNC) form. Record review showed that the resident, who had diagnoses including psychosis and hemiplegia, was severely cognitively impaired and unable to understand or process information. Despite this, the NOMNC form was provided directly to the resident, and there was no evidence that a responsible party or legal representative was involved in the notification process. The Social Services Director acknowledged that the resident was not capable of understanding the information and that a guardianship should have been pursued at the time of admission, but this was not done. Interviews with facility staff, including the DON, confirmed that the resident was mentally incapable of making decisions and that the NOMNC process was not properly followed. The facility's policy required that the NOMNC be issued to the resident or their representative when Medicare-covered services are ending, regardless of whether the resident is leaving or remaining in the facility. In this case, the lack of a guardian or representative meant the resident did not receive appropriate notification or the opportunity to exercise their rights regarding Medicare coverage changes.
Failure to Provide Timely Bed Hold Notice, Ombudsman Notification, and Discharge Planning
Penalty
Summary
The facility failed to complete required documentation and notifications related to transfer/discharge and discharge planning for two residents. For one resident with diabetes mellitus and major depressive disorder, the facility did not provide a written bed hold notice at the time of transfer to a general acute care hospital, instead relying on a previously signed form from admission and only obtaining a new signature upon the resident's return. Additionally, the Notice of Proposed Transfer and Discharge was not provided to the Ombudsman at the time of transfer, but rather two days later. Interviews with facility staff, including the Administrator, Social Services Director, and Director of Nursing, confirmed that the bed hold notice and Ombudsman notification should have been completed at the time of transfer, in accordance with facility policy. Record review and staff interviews further revealed that the Social Services Director did not assist another resident, who had anxiety, bipolar disorder, and congenital deformities, with discharge planning after the resident requested to move to an assisted living facility. The resident, who was cognitively intact and required some assistance with activities of daily living, reported that she had informed the Social Services Director of her desire to leave the facility weeks prior, but had not received any assistance or updates. The Social Services Director acknowledged responsibility for helping with placement and admitted to not starting the process, despite the resident being medically stable and safe for discharge. Facility policies reviewed indicated that written bed hold information must be provided prior to transfer, and that the Notice of Proposed Transfer and Discharge should be given to the Ombudsman at the time of transfer. The policies also require timely and accurate documentation to support resident care and legal compliance. The failure to follow these procedures resulted in incomplete documentation and lack of support for residents' rights and discharge planning.
Failure to Implement and Develop Comprehensive Care Plans for Residents with Seizure Disorder and Pressure Wound
Penalty
Summary
The facility failed to implement and document appropriate care plan interventions for two residents with significant medical needs. For one resident with a history of paranoid schizophrenia, epilepsy, and major depressive disorder, the care plan specified the use of padded side rails as a seizure precaution to prevent injury. Despite this documented intervention, observations on multiple occasions revealed that the resident's bed did not have padded side rails. Staff interviews confirmed that the intervention was not in place, and both the CNA and LVN acknowledged that the care plan was not being followed, which was also confirmed by the Director of Nursing. For another resident with chronic obstructive pulmonary disease, diabetes mellitus type II, and hemiplegia, the facility failed to develop a care plan addressing a newly identified open wound on the sacrococcyx. The resident required substantial assistance with mobility and had orders for specific wound care treatments. However, review of the records and staff interviews revealed that no care plan had been written for the wound, despite recommendations from a wound consult and ongoing wound care orders. The LVN responsible for the resident's care admitted to not creating the care plan due to being in training with the DON. The facility's own policy and procedure on comprehensive care plans requires that qualified staff are notified of their responsibilities and that care plans are developed and implemented to address residents' medical, nursing, and psychosocial needs. In both cases, the lack of implementation and development of care plans resulted in the potential for residents not receiving appropriate interventions as identified in their assessments.
Medication Administered Without Physician Order
Penalty
Summary
A licensed vocational nurse (LVN) administered 5 milliliters of Geritussin, an over-the-counter cough syrup, to a resident without a physician's order. The resident had a history of chronic obstructive pulmonary disease (COPD), epilepsy, hypothyroidism, and schizoaffective disorder, and was assessed as having moderately impaired cognitive skills, requiring assistance with daily activities. The LVN stated that she gave the medication due to the resident's cough and believed that, as an over-the-counter medication, it did not require a physician's order. Upon review, the LVN confirmed there was no physician order for Geritussin in the resident's records and was unsure of the facility's policy regarding administration of over-the-counter medications without a physician's order. The Director of Nursing (DON) confirmed that it was not the facility's practice or standard of care to administer any medication, including over-the-counter drugs, without a physician's order. The facility's policy and procedure on medication administration, revised in November 2017, specified that medications are to be administered by licensed nurses only as ordered by a physician and in accordance with professional standards of practice. The DON also noted that the LVN should have notified the physician about the resident's cough and obtained an order prior to administering the medication.
Failure to Provide Oral and Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and services to two residents who were dependent on staff for activities of daily living (ADLs), specifically in the areas of oral care and personal hygiene. One resident, with diagnoses including cerebral infarction, dementia, and aphasia, was observed with dry lips and a crusty yellowish film around the mouth. This resident was assessed as having severely impaired cognition and being fully dependent on staff for ADLs. During interviews, staff acknowledged the importance of oral care, especially for residents unable to perform self-care, and facility policy required oral care to be provided every shift and as needed. Another resident, with a history of cerebrovascular disease, hemiplegia, schizoaffective disorder, and major depressive disorder, was observed with long and dirty fingernails on both hands. This resident required partial to moderate assistance with personal hygiene and was care planned to receive ADL support and cues as needed. Observations showed the resident using dirty fingernails to eat, and staff interviews confirmed that fingernail care was not being consistently provided or communicated to the charge nurse as required by facility policy. Facility policies reviewed indicated that residents unable to perform ADLs should receive services to maintain good grooming, personal, and oral hygiene. However, direct observations and staff interviews demonstrated that these policies were not followed for the two residents, resulting in unmet hygiene needs.
Failure to Provide Replacement Eyeglasses for Resident with Impaired Vision
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including heart failure, chronic kidney disease, and anxiety, was identified as needing reading glasses following an eye consultation. The resident's Minimum Data Set indicated impaired vision, with the ability to see large print but not regular print, and a need for substantial assistance with activities of daily living. Despite this documented need, the resident was observed without eyeglasses after his previous pair broke, and he expressed agitation about not having replacement glasses. Interviews with facility staff revealed that a Certified Nursing Assistant had informed the Social Services Director (SSD) about the need for new eyeglasses approximately two weeks prior, but the SSD had not taken any action to address the issue. The SSD acknowledged awareness of the need for glasses for about a week but admitted to not following up. The Director of Nurses confirmed that the SSD should have contacted the optometrist upon being informed. The facility's policy requires ensuring access to vision services and assistive devices, but this was not followed in the resident's case.
Oxygen Tubing Labeling Deficiency
Penalty
Summary
A deficiency was identified when a resident who required intermittent oxygen therapy did not have their oxygen tubing labeled with a start date or change date. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, and hemiplegia, was noted to have severely impaired cognition and required substantial to maximal assistance for mobility. During an observation, it was found that the oxygen tubing in the resident's room lacked any labeling to indicate when it had been started or last changed. During an interview, an LVN confirmed that the facility's practice was to change oxygen tubing weekly, but acknowledged that there was no date label present on the tubing for this resident. The LVN also stated that failure to change the tubing as scheduled could present an infection control issue. Review of the facility's policy indicated that oxygen tubing should be changed weekly and labeled with the date of change, but this procedure was not followed in this instance.
Failure to Assess and Address PTSD Needs for Residents
Penalty
Summary
The facility failed to ensure that staff were competent and adequately prepared to meet the behavioral health needs of residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Specifically, two residents with PTSD were not properly assessed for their condition or for potential triggers upon admission. The Social Services Director (SSD) did not complete or document PTSD assessments for these residents, and there was no evidence of monitoring or interventions tailored to their behavioral health needs. The Director of Nursing (DON) confirmed that documentation regarding PTSD and triggers was missing and acknowledged that such assessments should have been completed at admission. Staff members, including Certified Nurse Assistants (CNAs) and Licensed Vocational Nurses (LVNs), were unaware of the residents' PTSD diagnoses and did not know what triggers to monitor for or how to provide appropriate care. Interviews with the residents revealed that they had not been approached about their PTSD or triggers, and one resident expressed discomfort and anxiety due to staff not being informed about his specific triggers, such as loud noises and large groups. The lack of staff awareness and training resulted in the absence of individualized interventions to address the residents' mental health needs. A review of facility policies and job descriptions indicated that the Social Services Director was responsible for completing comprehensive assessments and care plans, including identifying and addressing mental and psychosocial needs. However, these responsibilities were not fulfilled, as evidenced by the lack of PTSD assessments and individualized care planning for the affected residents. The facility's policy also required nursing staff to identify and document mental health conditions and behaviors, which was not done in these cases.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that the required social services were not delivered to residents as needed. The lack of these services directly impacted the residents' ability to attain or maintain their optimal well-being.
Failure to Protect Resident Information and Ensure Accurate Medical Documentation
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards. During an observation, a CNA left an open binder containing residents' activities of daily living (ADL) documentation unattended on a bedside table near a resident's room while assisting another resident. Interviews with the CNA, another CNA, and the DON confirmed that the binder contained confidential health information and should have been closed and returned to the nursing station to protect resident privacy. The facility's policy required reasonable and appropriate measures to protect the confidentiality of resident information. Additionally, the facility failed to ensure the accurate transcription of a physician's telephone order for wound care for a resident with multiple diagnoses, including COPD, diabetes mellitus type II, and hemiplegia, who had severely impaired cognition and required substantial assistance. The telephone order for collagenase ointment application to a pressure ulcer did not include instructions for a dry dressing, which the LVN acknowledged was an omission. The facility's policy required that all resident documentation be complete and accurate, but this was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Administration Errors Due to Non-Compliance with Physician Parameters
Penalty
Summary
The facility failed to ensure that licensed vocational nurses (LVNs) were competent during medication administration, resulting in two residents receiving blood pressure-lowering medications that did not meet the physician's specified parameters. Resident 2, who was admitted with hypertension and dementia, had orders for several medications with specific instructions to hold administration if the systolic blood pressure (SBP) or heart rate (HR) fell below certain thresholds. However, the Medication Administration Report (MAR) showed that these medications were administered on multiple occasions despite the residents' blood pressure readings being below the prescribed parameters. Similarly, Resident 1, who was admitted with heart failure and a hypertensive emergency, had orders for medications with parameters to hold administration if the SBP or HR was below specified levels. The MAR indicated that these medications were also administered when the resident's blood pressure readings were below the physician's parameters. The Director of Nursing (DON) confirmed that the facility's policy required checking blood pressure before administering medication and holding it if the readings were outside the physician's parameters. The DON acknowledged that multiple LVNs failed to follow these orders, resulting in significant medication errors. The facility's policy and procedure documents emphasized the importance of obtaining and recording vital signs before medication administration and holding medications if vital signs were outside prescribed parameters. The DON stated that the failure to follow these orders was a significant medication error and that the LVNs involved were not competent in medication administration, which could potentially harm residents.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors by not adhering to physician-ordered parameters when administering blood pressure-lowering medications. Resident 2, who was admitted with hypertension and dementia, had specific instructions to hold certain medications if the systolic blood pressure (SBP) or heart rate (HR) fell below specified levels. However, the Medication Administration Report (MAR) indicated that medications such as Cozaar, Isosorbide Mononitrate, Toprol XL, and Norvasc were administered despite the residents' blood pressure readings being below the prescribed parameters on multiple occasions. Similarly, Resident 1, who was admitted with heart failure and a hypertensive emergency, had orders to hold medications like Entresto, Lasix, and Toprol XL if the SBP or HR was below certain thresholds. The MAR showed that these medications were given even when the blood pressure readings were below the physician's parameters. The Director of Nursing (DON) confirmed that the facility's policy required checking blood pressure before administering medication and holding the medication if the readings were outside the physician's parameters. The facility's policy and procedure documents emphasized the importance of obtaining and recording vital signs before medication administration and holding medications if the vital signs were outside the prescribed parameters. The DON acknowledged that the nurses did not follow the physician's orders for the two residents, resulting in significant medication errors. The facility's policy on medication errors required ensuring that the facility was free of significant medication error events.
Failure to Provide Safe Transfer Assistance for High-Risk Resident
Penalty
Summary
The facility failed to ensure a resident, who was assessed as high risk for falls and required assistance during transfers, was provided with safe and appropriate transfer assistance. The deficiency involved a Certified Nurse Assistant (CNA) not utilizing a gait belt during the transfer of the resident, who had functional limitations and required substantial assistance. The resident, who had a left above-the-knee amputation and was at risk for falls, was transferred without the necessary two-person assistance, leading to a fall. The resident's Care Plan did not specify the requirement for two-person assistance during transfers, which was a deviation from the facility's procedure for transferring residents from a bed to a wheelchair. The CNA attempted to transfer the resident alone, without a gait belt, and was unable to support the resident's weight, resulting in the resident being lowered to the floor. Interviews with staff revealed inconsistencies in the understanding and application of transfer procedures, with some CNAs opting for assistance based on their physical capability rather than following a standardized protocol. The Director of Staff Development and the Director of Nursing acknowledged that the Care Plan should have reflected the need for two-person assistance and the use of a gait belt. The facility's policies on fall prevention and the use of gait belts were not adhered to, placing the resident at risk for serious injury. The incident highlighted a lack of compliance with established procedures designed to ensure resident safety during transfers.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure that a grievance was investigated and resolved promptly for a resident who had voiced a concern. The resident, who had diagnoses including anxiety disorder, nicotine dependence, and mood affective disorder, reported an incident involving a Certified Nursing Assistant (CNA) who lit a butane lighter close to the resident's face, causing fear of being burned. The resident had no cognitive impairment and required assistance for all activities of daily living. Despite the resident's complaint to the Administrator, there was no documentation of any investigation into the incident in the nursing progress notes or the social services grievance and complaint log. During an interview, the Administrator acknowledged that the complaint was not investigated because the focus was on another physical abuse allegation involving a different resident. The Activity Assistant corroborated the resident's account, having witnessed the CNA lighting the cigarette with the flame close to the resident's face, although it was unclear if it was intentional. The lack of investigation into the resident's grievance represents a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by the facility's grievance policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for a resident, which had the potential to increase the risk of falls and injury. The resident, who was admitted with diagnoses including epilepsy, extrapyramidal and movement disorder, and schizoaffective disorder, required supervision with certain activities according to the Minimum Data Set. Despite being identified as a high fall risk after a fall incident, the care plan was not updated with new interventions following the fall. The resident experienced a fall resulting in an abrasion to the back of the head and was subsequently transferred to a General Acute Care Hospital. During an interview, the resident mentioned not using the call light before getting out of bed, which led to the fall. The Director of Nursing acknowledged that the care plan lacked new interventions post-fall, which was against the facility's policy to update care plans after such incidents. The facility's policies on comprehensive care planning and fall prevention were not adhered to, as evidenced by the lack of updates to the resident's care plan after the fall.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure a safe environment for five residents who were smokers by not implementing the guidance from the Resident Smoking Assessment Form. This form indicated that all residents' smoking materials and paraphernalia must be safely stored by facility staff. However, observations revealed that residents were in possession of smoking materials such as cigarettes and lighters, which were not secured by the staff as required. This oversight was evident in the cases of Residents 6, 117, 122, 141, and 157, who were found with smoking materials in their possession. Additionally, the facility did not provide adequate supervision for residents identified as unsafe smokers. Residents 141, 157, and 117 were observed smoking without staff supervision, despite their assessments indicating they required constant supervision due to their inability to safely handle smoking materials. For instance, Resident 141 was seen smoking on the patio without staff monitoring, and Resident 157 was observed lighting a cigarette for another resident without supervision. These actions were contrary to the facility's policy, which required staff to monitor residents while smoking to prevent accidents. The facility also failed to adhere to its policies and procedures regarding accidents and supervision. The policy stated that staff should observe and identify potential hazards in the environment, yet residents were found with smoking materials in their rooms and on their person. Interviews with staff revealed a lack of enforcement of the smoking policy, as some staff members were aware of residents possessing smoking items but did not confiscate them. This lack of adherence to policy and supervision posed a significant risk of fire and injury to the residents and others in the facility.
Failure to Employ Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker as required for a facility licensed for more than 120 residents. The Social Service Director (SSD) was interviewed and revealed that the facility was licensed for 195 residents and acknowledged the need for a full-time Social Worker to meet the residents' needs. However, the SSD did not have a set schedule as the Director of the Social Service Department and also worked as a Certified Nurse Assistant (CNA). The SSD had two assistants in the Social Service Department, but they were not qualified to become directors. The SSD could not provide evidence of working full-time as the Director of the Social Service Department. Further investigation with the Director of Staff Development (DSD) revealed that the SSD did not meet the required full-time hours per week for the position. The SSD had transitioned to working full-time as a CNA to earn overtime pay while working part-time as the SSD. The DSD had informed the Administrator (ADM) about the SSD's part-time hours, but no action was taken. The ADM acknowledged the facility's need for a full-time Social Worker and admitted that previous hires for the position had resigned. The facility's job description for the SSD confirmed the requirement for a full-time qualified Social Worker in facilities with more than 120 beds.
Deficiencies in Social Worker Employment and Smoking Supervision
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to employ a qualified social worker on a full-time basis, as required by regulations for facilities licensed to more than 120 residents. This deficiency was identified during an interview and record review with the Administrator, who acknowledged the absence of a full-time Social Service Director (SSD) despite the facility's need to meet the psychosocial needs of all residents. The Administrator admitted that the issue was not addressed or discussed during QAPI meetings, and there was no policy or procedure developed for hiring a full-time SSD. Additionally, the facility did not provide adequate supervision for residents identified as unsafe smokers, nor did it evaluate the provisions of care or develop a policy and procedure for routinely checking cigarettes and lighters. This oversight was acknowledged by the Administrator during a QAPI interview, where it was revealed that the facility lacked knowledge regarding the necessary supervision and monitoring for these residents. The facility's existing policy and procedure for QAPI, revised in 2021, emphasized the need for a comprehensive, data-driven program focusing on care outcomes and quality of life, yet failed to address these specific safety concerns.
Resident Dignity Compromised Due to Lack of Proper Footwear
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was treated with dignity by allowing them to walk around the facility without proper footwear. Resident 12, who has a history of schizoaffective disorder, bipolar disorder, and chronic kidney disease, was observed on multiple occasions walking in the facility and outside on the smoking patio wearing only socks, which were not non-slip. The resident's Minimum Data Set indicated a need for moderate assistance with dressing and footwear, highlighting the facility's responsibility to assist the resident in wearing appropriate shoes. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, confirmed that Resident 12 should have been wearing shoes and that the facility failed to ensure this. The staff acknowledged the importance of wearing shoes for the resident's dignity and to create a home-like environment. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of treating residents with respect and ensuring their quality of life, which was not upheld in this instance.
Incomplete POLST Form for a Resident
Penalty
Summary
The facility failed to complete the Physician Orders for Life-Sustaining Treatment (POLST) form for one of the residents, identified as Resident 125. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 125, who was initially admitted and later readmitted to the facility, had diagnoses including major depressive disorder, neuralgia, and pancreatitis. The resident's History and Physical indicated they had the capacity to understand and make decisions. However, the POLST form, which is crucial for outlining the resident's treatment preferences in case of a medical emergency, was found to be incomplete, specifically in Part D, during a review conducted on a specified date. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the POLST form was supposed to be reviewed quarterly, but it remained incomplete. Both the SSD and DON acknowledged the importance of having a completed POLST to ensure that the resident's wishes are respected and carried out, especially if the resident becomes incapacitated. The facility's policy and procedure on POLST forms emphasized the need for careful decision-making by the resident and outlined the process for completing and reviewing these forms. Despite this policy, the failure to complete the POLST form for Resident 125 was noted as a deficiency.
Failure to Notify Resident of Medicare Coverage Changes
Penalty
Summary
The facility failed to provide appropriate notification to a resident regarding changes in their Medicare coverage, specifically through the provision of the Notice of Medicare Non-Coverage (NOMNC) form. This deficiency was identified during a review of Resident 237's records and an interview with the Social Service Director (SSD). Resident 237, who was admitted and readmitted to the facility with diagnoses including paranoid schizophrenia, unspecified glaucoma, and dysphagia, had severely impaired cognitive skills for daily decision-making. The Minimum Data Set (MDS) indicated that the resident required set-up assistance for eating, oral hygiene, and upper body dressing. The SSD acknowledged that the NOMNC form for Resident 237 was not signed, indicating that the resident or their representative was not notified of the appeal process. The SSD admitted responsibility for completing, providing, and explaining the NOMNC to the resident or their representative. The facility's policy and procedure on Advance Beneficiary Notice required that the NOMNC be issued when Medicare-covered services are ending, regardless of whether the resident is leaving or staying in the facility. The policy also stated that if the notice could not be hand-delivered, a telephone notice should be made, followed by a mailed, emailed, faxed, or hand-delivered notice, with documentation complying with form instructions regarding telephone notices.
Failure to Implement Behavioral Interventions Before Transfer
Penalty
Summary
The facility failed to implement behavioral modification and dementia care techniques for a resident before notifying the physician, which could have led to an inappropriate assessment and transfer. The resident, who had intact cognition, was admitted with diagnoses including Type 2 diabetes mellitus, hypothyroidism, and hypertensive heart disease. Interviews with staff revealed that the resident was alert but sometimes confused, expressing a desire to go home with her son. Despite being trained to handle behavioral issues, staff did not document any interventions or encouragements to address the resident's agitation, such as facilitating communication with her son. The Director of Nursing acknowledged that there was insufficient documentation regarding the resident's behavior and the interventions taken. The nurse's notes lacked clarity on whether the resident's son was contacted during periods of agitation. The facility's policy on transfer and discharge requires that a resident should not be transferred unless their needs cannot be met at the facility. In this case, the resident's needs could have potentially been met by involving the son, as suggested by the DON.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that the Notice of Proposed Transfer/Discharge form was completed and sent to the Office of the State Long-Term Ombudsman for a resident who was transferred to a general acute care hospital. This oversight was identified during a review of the resident's admission records and interviews with facility staff. The resident, who had intact cognition and was capable of understanding and making decisions, was initially admitted to the facility with diagnoses including Type 2 diabetes mellitus with hyperglycemia, hypothyroidism, and hypertensive heart disease without heart failure. Interviews with the Social Worker and Director of Nursing revealed that the facility's process involved social services faxing transfer forms to the Ombudsman. However, the fax records for the resident in question were not found. The Administrator confirmed that the notice of transfer and discharge is typically filled out by nursing staff and signed by the resident, with the intention of sending it to the Ombudsman the following day. The facility's policy indicated that a copy of the notice should be provided to the Ombudsman, but this was not adhered to in this instance.
Incorrect MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure the correct encoding of a resident's discharge status on the Minimum Data Set (MDS), which is a resident care and screening assessment tool. This deficiency involved Resident 186, who was initially admitted to the facility with diagnoses including Type 2 diabetes mellitus with hyperglycemia, hypothyroidism, and hypertensive heart disease without heart failure. During a review of Resident 186's MDS, it was found that the discharge status was incorrectly coded as a transfer to a hospital instead of a discharge to home or community. This error was identified during an interview and concurrent record review with the MDS nurse, who acknowledged the mistake and explained that incorrect coding could lead to a lack of continuity of care, as the facility would not know the resident's actual discharge location. The MDS nurse also noted the importance of accurate data for CMS quality measures, which track discharges to the community.
Incomplete Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure a complete dental assessment for one of the six sampled residents, identified as Resident 126, upon admission. The deficiency was identified during a review of Resident 126's records, which showed that the Oral/Dental Assessment conducted on two occasions, 7/1/2024 and 4/12/2024, was incomplete. Specifically, the assessment lacked check marks to verify whether Resident 126 could function without dentures and if the resident desired dentures to be made. Interviews with RN 1 and the Director of Nursing (DON) confirmed that the dental assessment was not completed, which was necessary to determine the resident's need for dentures. Resident 126 had a medical history that included major depressive disorder, schizoaffective disorder, and oropharyngeal dysphagia, which could impact their ability to make decisions and their nutritional intake. The facility's policy and procedure for dental services required that residents' dental needs be identified through physical assessments and documented accordingly. The failure to complete the dental assessment potentially placed Resident 126 at risk of not receiving adequate nutrition due to the inability to chew food properly without dentures.
Failure to Complete PASARR Level II Screening
Penalty
Summary
The facility failed to complete and transmit a PASARR Level II Screening for a resident with suspected mental illness. During an interview and record review, it was found that the resident's PASARR Level I Screening, dated May 1, 2024, indicated the need for a Level II Screening due to suspected mental illness. However, the Level II Screening was not completed. The Registered Nurse (RN) confirmed that the screening was required but not performed. The Director of Nursing (DON) stated that the PASARR Level II Screening should be completed prior to admission, and the admitting RN was responsible for following up on incomplete screenings. The resident's psychiatric evaluation from a General Acute Care Hospital indicated diagnoses of schizophrenia and schizoaffective bipolar disorder. The facility's policy required screening in accordance with the State's Medicaid rule and prompt referral for additional review if a serious mental disorder was evident.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives, timeframes, and interventions for three residents. Resident 61, who had bilateral bed rails, did not have a care plan addressing the use of these rails. Despite being cognitively intact and expressing a preference for the bed rails, there was no documented device assessment, doctor's order, or signed consent for their use. The facility's policy required that the use of side rails be addressed in the resident's care plan, which was not done. Resident 6, who was a smoker, also lacked a comprehensive care plan. The resident had the capacity to understand and make decisions, yet there was no care plan to manage their smoking habits safely. The facility's policy indicated that safe smoking measures should be documented in the resident's care plan, but this was not followed, leaving staff without guidance on how to prevent potential injuries related to smoking. Resident 139 refused dental services, specifically the recommendation for new dentures/partials. Despite the refusal, no care plan was developed to address the risks associated with not having dentures, such as weight loss and difficulty chewing. The facility's policy required that comprehensive person-centered care plans be developed based on assessments, but this was not done for Resident 139, leading to a breakdown in communication and care management.
Failure to Revise Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to revise the care plan for a resident who was at risk for falls due to not wearing shoes. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and chronic kidney disease, was noted to have fluctuating capacity to understand and make decisions. The Minimum Data Set indicated that the resident required moderate assistance with activities of daily living, including dressing and putting on footwear. Despite being redirectable and needing regular reminders to wear shoes, the care plan was not updated to reflect this need. During interviews and record reviews, both the Licensed Vocational Nurse and the Director of Nursing acknowledged that the care plan should have been revised to include strategies for encouraging the resident to wear shoes. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of individualized care, but the care plan did not address the resident's refusal to wear shoes, which placed the resident at risk for falls.
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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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