Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1205 8th Street, Bakersfield, California 93304
- CMS Provider Number
- 555229
- Inspections on file
- 56
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Valley Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a functional call system in both shower rooms, where one shower room lacked any call system and the other had a wireless call button that did not activate an alarm at the nurses station. The MS confirmed there was no working call system in these areas and acknowledged that replacement wireless buttons frequently went missing. The DON stated that the shower room call systems had been nonfunctional as an ongoing issue and confirmed that two residents using the toilet in one shower room were at high risk for falls, with one resident having a high Morse Fall Scale score and another having severe cognitive impairment and a high fall risk score. One resident reported independently using the toilet in the shower room and confirmed there was no call system available, despite facility policy requiring call systems in toileting and bathing areas and designating bathroom call bells as emergency calls.
The facility failed to develop and implement required care plans for three residents. One resident with mobility limitations and a right foot amputation was documented as preparing and using marijuana in his room, staying in his car all night blocking the entrance, and continuing to drive despite an unresolved surgical wound, yet no care plan addressed his substance use or driving. Another resident left the facility with an ex‑spouse and did not return for several days, and there was no care plan for this pattern of non‑compliance or leaving without informing staff. A third resident was receiving Cresemba per MD orders, but no care plan addressed this antifungal medication therapy. These omissions occurred despite a facility policy requiring comprehensive, person‑centered care plans based on assessed needs.
A cognitively intact resident with significant mobility limitations and a healing surgical foot wound repeatedly left the facility and drove a personal vehicle without a physician out-on-pass order, without notifying licensed staff, and without required nursing assessments before leaving or upon return, despite a facility policy mandating physician authorization, nurse assessment, and proper sign-out/sign-in. In a separate case, a resident with a GT and documented skin irritation around the GT site did not receive GT site care every shift as ordered by the physician, the dressing was observed to be soiled, not covering the insertion site, and leaking formula, CNAs did not report the condition to licensed staff, and no care plan was developed to address the GT-related skin irritation, contrary to the facility’s wound management policy requiring ongoing skin assessment and care planning.
The facility did not submit the results of an investigation into an allegation of resident-to-resident abuse to CDPH within the required five-day period, instead providing the report ten days after the incident, contrary to facility policy.
A deficiency was cited for not ensuring a safe, clean, comfortable, and homelike environment for a resident, including the safe provision of treatment and daily living supports.
A resident dependent on a G-tube and at risk for dehydration did not receive physician-ordered water flushes or documented hydration, despite a dietician's recommendation. Staff failed to obtain necessary orders, communicate recommendations, and monitor intake and output as required, resulting in the resident being hospitalized for sepsis, hypernatremia, and severe dehydration.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The QAPI committee did not identify or document non-functional restroom call lights, resulting in an unsafe environment for all residents. The Medical Director, Administrator, and Maintenance Supervisor were unaware of the issue, and facility records did not reflect any monitoring or corrective action regarding the call light system.
Surveyors found that call light systems in all resident bathrooms and shower rooms were non-functional or inaccessible, preventing residents from alerting staff for assistance while using these areas. Facility policy required operational call systems, but none were working or properly placed at the time of the survey.
Surveyors observed two medication carts left unsecured and unattended, with one cart's drawers unlocked and accessible, and a jar of Lactulose left on top of another cart while a nurse administered medications to a resident. The DON was unable to secure the cart's locking mechanism, and staff acknowledged the lapse in medication security, contrary to facility policy.
Three dietary staff did not follow CDC-recommended handwashing procedures, applying soap before wetting their hands and not adhering to the correct sequence. The facility's hand hygiene policy and posted instructions also did not match CDC guidelines. Additionally, the facility lacked a written inventory for PPE, relying on visual checks by the Supplies Supervisor rather than documented tracking.
A review of facility documentation and resident assignments revealed that 23 rooms did not provide the required 80 square feet per resident in multiple occupancy rooms, with some rooms offering as little as 66 to 77 square feet per resident. The Administrator confirmed the deficiency, and no residents were found to be negatively affected at the time of the survey.
A resident's diet was changed from regular to pureed at the request of the resident, but the responsible party was not notified of this change. The DON confirmed that nurses could downgrade diet consistency without physician notification, but there was no documentation that the responsible party was informed, contrary to facility policy.
Two residents receiving dialysis did not receive complete nursing assessments as required, with missing pain and respiratory assessments before and after dialysis sessions. Facility policy mandates such monitoring and documentation, but staff interviews and record reviews confirmed these steps were not followed.
Surveyors found that the kitchen's two compartment sink, used for washing produce and food, lacked an air gap for backflow prevention. Staff confirmed the absence of an air gap, and dietary staff were observed washing fresh strawberries in the sink. The facility did not have a policy addressing air gaps, and the Director of Maintenance stated it was not possible to create one in the current setup.
The facility failed to develop and implement care plans for two residents at high risk for falls, leading to potential accidents and injuries. One resident had a high fall risk score but no care plan, while another experienced two falls with injuries before a care plan was initiated. The facility's policy requires individualized care plans based on fall risk assessments, which was not followed.
The facility failed to notify the MDs of two residents and the RP of one resident about abuse allegations, as required by its Abuse Prevention and Prohibition Program policy. The DON and Administrator confirmed the absence of documentation in the residents' medical records, which should have been recorded in a progress note.
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. Despite allegations of abuse and neglect, the required psychosocial monitoring was not documented consistently over a 72-hour period, as confirmed by the DON.
The facility failed to provide reasonable access to a telephone that ensured privacy for three residents. Staff and residents confirmed that phone calls had to be made in non-private areas like the Administrator's office or the nursing station, and the facility lacked portable phones. This issue was acknowledged by multiple staff members and contradicted the facility's policy on telephone access.
A resident admitted with hemiplegia and reduced mobility was not assessed for pressure injury risk, and their left heel redness was not reported to a physician or treated. No care plan or IDT meeting was conducted, leading to the development of a Stage 3 pressure injury.
The facility failed to ensure accurate medical records for a resident, as confirmed by the DON. The resident's Wound Weekly Observation Tool indicated an SDTI, while the care plan incorrectly documented it as a stage 3 pressure injury. The facility's policy mandates accurate and chronological documentation, which was not followed in this case.
The facility failed to follow their policy on contacting APS when a resident with multiple health issues and moderate cognitive impairment left AMA. The resident's responsible party was not contacted, and arrangements for continued dialysis were not made.
The facility failed to ensure that air mattresses for three residents were set correctly according to their weights, leading to potential safety risks. Observations and interviews revealed that neither the nurses nor the maintenance worker were trained or responsible for setting the correct air mattress settings, and the facility lacked policies for such training.
A facility failed to provide oxygen per physician's orders for a resident with COPD, pneumonia, and respiratory failure. The resident was observed receiving oxygen at six liters per minute instead of the prescribed two liters per minute, contrary to the facility's policy and procedure for oxygen administration.
The facility failed to provide proper foot care for two residents, resulting in pain and discomfort. LVNs did not perform adequate skin assessments or develop care plans, and CNAs failed to report and document observations. The podiatrist did not provide appropriate treatment, leading to neglected foot conditions.
The facility failed to complete activity assessments for 16 residents within the required seven days of admission, as confirmed by the Activity Director. This oversight could impact the residents' physical, mental, and psychosocial well-being.
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. Interviews revealed that a Certified Wound Nurse did not receive on-the-job training, and the Director of Nursing admitted that no competency assessments were being conducted. The Director of Staff Development confirmed the absence of documented skills competency assessments, and the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff.
The facility failed to maintain kitchen sanitation, properly store and label food, ensure staff followed dress code policies, and serve food in a sanitary manner. Observations included a dirty ladder and scaffolding in the kitchen, unsealed and unlabeled food items, and staff with uncovered facial hair. Additionally, a Dietary Supervisor returned a plated portion of food to the serving line, which was deemed inappropriate.
The facility failed to ensure proper infection control practices for residents, including not wearing PPE, not performing hand hygiene, and not addressing bowel movement leakage. Staff also mishandled trash and laundry without proper hygiene, and the infection preventionist did not maintain records of surveillance activities or properly stock isolation carts.
The facility failed to ensure accurate records of Influenza and Pneumonia vaccinations for all residents. The Infection Control Preventionist could not provide vaccination records for 11 residents and could not verify pneumonia vaccination status for 40 residents. Only seven residents had signed declination statements, and the facility lacked a policy for these vaccinations.
The facility failed to ensure the Infection Preventionist (IP) maintained accurate records of employee COVID-19 vaccinations for 110 of 159 employees. The IP did not have a log of vaccinations and only had 49 vaccination cards on file. The IP admitted to requesting the cards verbally but did not follow up, resulting in incomplete records.
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 residents. No competency assessments or specific training for psychological or mental disorders were conducted, leaving staff unprepared to address residents' behavioral health needs.
The facility failed to ensure timely completion of MDS assessments for three residents. Quarterly and annual assessments were either not transmitted or still in progress, contrary to the facility's policy and procedures. This was confirmed during interviews and record reviews with the MDS Coordinator.
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents. The absence of these reviews was confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON).
The facility failed to ensure that two residents had access to a call light, which had the potential for unmet care needs. One resident's call light was found on the floor, and another's was hanging on the wall behind the headboard, both out of reach. Staff acknowledged that the call lights should have been within the residents' reach.
The facility failed to notify the responsible party of a resident's change in condition, despite the resident lacking the capacity to make their own decisions. The resident had a skin tear, and the responsible party was not informed, contrary to the facility's policy.
The facility failed to obtain proper authorization for a resident's transfer, allowing a cognitively impaired resident to sign documents despite a physician's certification of incapacity. The responsible party was not notified, leading to confusion and potential risk.
The facility failed to develop and implement care plans for two residents, leading to potential negative outcomes. One resident repeatedly refused medical care without a specific care plan in place, and another resident did not have a care plan developed after a fall, contrary to the facility's policies.
The facility failed to provide preventive measures for pressure injuries for a resident with quadriplegia and did not ensure weekly wound assessments for two residents. The lack of a pressure-relieving mattress and appropriate dressings, along with inadequate repositioning, contributed to skin breakdown. Additionally, required weekly wound assessments and documentation were not completed, hindering the monitoring of wound healing progress.
The facility failed to assess five residents for bed entrapment risk before applying bedrails, despite having a policy requiring such assessments. The Maintenance Supervisor and Minimum Data Set Coordinator confirmed that no assessments or documentation had been completed.
The facility failed to ensure an RN was scheduled and on duty for eight hours a day, seven days a week. A review of the nursing staffing schedule for October, November, and December 2023 revealed multiple dates where no RN was on duty for the required hours. The facility's policy required an adequate number of nursing personnel, including at least one RN in the facility at all times for facilities licensed for 60 to 99 beds, in addition to the DON.
The facility failed to maintain a medication error rate below five percent, with two errors occurring in 29 opportunities. A nurse did not administer a resident's blood-thinning medication, and another nurse did not provide an inhaler for COPD due to unavailability. The DON stated that nurses should call the pharmacy in advance to prevent running out of medications.
The facility failed to ensure the safe administration of medication for a resident when an albuterol inhaler was found on the bedside table. Two LVNs acknowledged the oversight, which violated the facility's policy requiring secure storage of medications.
The facility failed to assess and update a resident's food preferences, leading to dissatisfaction with the food served. The Dietary Supervisor had not reviewed the resident's preferences since admission, contrary to facility policy.
A resident with cerebral infarction, hemiplegia, hemiparesis, and dysphagia was given a mechanical soft diet instead of the prescribed pureed diet with nectar thick liquids. The CNA and CDM admitted to the error, which was against the facility's policy requiring adherence to physician-prescribed diet orders.
The facility failed to provide a language-assistance service for a resident who spoke a language native to the Punjab region of Pakistan. CNAs used Google Translate to communicate, as the facility lacked a formal translation service, leading to frustration and unmet care needs. The Administrator-in-Training admitted the facility did not have a translation service and relied on calling staff at home or contacting the Ombudsman for translation needs.
The facility failed to provide a summary of the Baseline Care Plan (BCP) within 48 hours of admission for four residents, leading to incomplete or missing care plans. This included residents with serious conditions such as Type 2 Diabetes Mellitus, Hemiplegia, Metabolic Encephalopathy, Sepsis, Unspecified Dementia, and Mood Disorder.
The facility failed to administer Percocet according to the physician's order for a resident, administering it for pain levels of 5 and 6 instead of the prescribed severe pain levels of 7-10. The DON confirmed this discrepancy during an interview and record review.
The facility failed to notify an MD of a resident's extremely high blood pressure and did not conduct IDT meetings for the resident's new wound issues. The DON and TN confirmed these lapses, which are against the facility's policy and procedure.
The facility failed to complete fall risk assessments for two residents. One resident did not have an assessment on admission despite having conditions like lack of coordination and reduced mobility. Another resident who fell did not have a quarterly or post-fall risk assessment completed.
Failure to Maintain Functional Call System in Shower Rooms
Penalty
Summary
The facility failed to ensure that a functional call system was available in resident bathrooms and bathing areas, specifically in both shower rooms at station 2 and station 3. During an observation and interview in the station 3 shower room with the Maintenance Supervisor (MS), surveyors noted there was no call system present for residents using the toilet or shower. The MS confirmed there was no call system available and stated there should have been an alternative call system provided for residents in these areas. In the station 2 shower room, a black wireless call button with a bell logo was observed hanging on the handrail next to the toilet. When the MS pressed this button and then went to nurses station 1, no alarm was heard, and the MS acknowledged that an alarm should have sounded to alert staff that assistance was needed in the shower room. The MS reported that he would replace the black wireless call buttons in the shower rooms but that these buttons would go missing, and reiterated that there should have been a functional call system available for residents using the toilet and shower. The DON stated that the facility had two shower rooms (station 2 and station 3) and that the call system in these shower rooms had not been working, describing it as an ongoing issue. The DON confirmed that residents using the toilet in the station 3 shower room, including Resident 85 and Resident 14, were at risk for falls and that the absence of a call system in the shower rooms would put residents at risk for accidents and falls. Resident 85’s Morse Fall Scale (MFS), dated 12/9/25, showed a score of 55, indicating high fall risk, and Resident 14’s MDS showed a BIMS score of 6, indicating severe cognitive impairment, with an MFS score of 60. Resident 14 reported independently using the toilet in the station 3 shower room and stated there was no call system there. The facility’s policy titled “Communication – Call System” required the facility to provide a call system in resident rooms and toileting/bathing facilities and identified bathroom call bells as emergency calls that must be answered promptly.
Failure to Develop and Implement Care Plans for Substance Use, Non‑Compliance, and Antifungal Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents, as required by its care planning policy. For one resident with a BIMS score indicating intact cognition, documented functional limitations in range of motion, wheelchair dependence, and a right foot amputation, multiple behavior notes and staff interviews showed that he prepared and used marijuana in his room, stayed in his car all night blocking the entrance while playing loud music, and continued to drive his car despite his amputation and an unresolved surgical wound. The Social Services Director and DON confirmed that the resident had been seen using marijuana, had nearly hit several cars in the parking lot, and that there was no care plan addressing his use of illegal substances or his driving, with the DON stating the facility did not know how to keep him safe when driving and acknowledging that the care planning policy was not followed. A second resident left the facility with an ex‑spouse and did not return for several days, and the Social Services Director confirmed there was no care plan addressing this resident’s pattern of non‑compliance or leaving the facility without informing staff. For a third resident, record review showed an active physician order for Cresemba, an anti‑fungal (anti‑viral/fungal) medication, but the Infection Prevention Nurse was unable to provide evidence of any care plan developed and implemented to address this medication therapy. The facility’s written care planning policy, which requires a comprehensive person‑centered care plan for each resident based on assessed needs, including services required and any services not provided due to exercise of resident rights, was not followed in these cases.
Failure to Follow Out-on-Pass and GT Wound Management Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its “Out on Pass” policy for a cognitively intact resident with significant physical limitations and an unresolved surgical wound. The resident’s MDS showed a BIMS score of 13, functional limitations in range of motion on one side of both upper and lower extremities, wheelchair dependence, inability to walk, and a need for supervision or touching assistance with transfers and setup assistance for wheelchair mobility. A medical progress note documented a history of need for assistance with personal care and generalized muscle weakness, with comments indicating a need for supervision and care 24 hours a day. The resident reported having all toes amputated on the right foot, with a healing surgical wound, and was observed with a dry dressing wrapped around the right foot. Record review showed that the resident purchased a vehicle and was leaving the facility without a physician out-on-pass order. The order summary report confirmed there was no physician order for out on pass. The facility’s out-on-pass log for the month showed multiple instances where the resident signed out but did not sign back in on return. Staff interviews revealed that the resident had been seen using marijuana in the facility and driving his car, with the social services director stating the resident had almost hit several cars in the parking lot. The DON and social services director both stated the resident would leave without notifying licensed nurses, preventing timely notification of the physician, and the DON confirmed the resident did not have a physician order to go out on pass. Further review of nursing notes showed that on one occasion the morning nurse reported the resident had signed out in the afternoon, was seen leaving during rounds, and had not returned by the time of the evening medication pass, with a later note documenting the resident’s return. The DON stated the resident was not assessed by a licensed nurse prior to leaving or upon returning to the facility, despite the facility’s written policy requiring a licensed nurse to assess the resident’s physical and mental status before leaving and to reassess upon return. The DON acknowledged that the policy, which also requires a physician order for passes and verbal notification to a licensed nurse before leaving, was not followed. The deficiency also includes the facility’s failure to follow its wound management policy and physician orders for treatment of a resident’s gastrostomy tube (GT) site. On admission, nursing documentation indicated the resident had a GT with skin irritation. The physician’s order summary directed staff to cleanse the GT site with normal saline, pat dry, apply zinc oxide to the peri-wound area, cover with a T-drain sponge, and secure with tape every shift. However, the treatment administration record showed the ordered treatment was only being performed on the day and evening shifts, not every shift as ordered. The treatment nurse confirmed the order was not followed and that there was no physician order to monitor the GT site as needed. During observation, the resident’s GT dressing was black, did not cover the insertion site, and the GT site was red and leaking yellow liquid. The treatment nurse stated the dressing was wet from leaking GT formula and that the moisture was causing irritation and redness around the site, and also stated the GT site should have been monitored as needed to keep it clean and dry. A CNA reported seeing the resident earlier with a black dressing that did not cover the GT site and acknowledged she did not notify the treatment nurse or any licensed nurse, stating she should have done so. Review of the care plan showed there was no care plan developed to address the skin irritation at the GT site, despite the DON stating the irritation was caused by leaking GT formula and that there should have been a care plan to monitor when the dressing needed to be changed. The facility’s wound management policy required a licensed nurse to perform skin assessments and develop a care plan based on physician recommendations, and the DON stated this policy was not followed.
Failure to Timely Report Investigation Results of Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of resident-to-resident abuse to the California Department of Public Health (CDPH) within the required five-day timeframe. According to the SOC 341 form, the facility became aware of the abuse allegation involving two residents and reported the initial incident to CDPH the following day. However, although the facility completed its investigative report, it did not submit the results to CDPH until ten days after the incident. The facility's own policy and procedures require that the state survey agent receive a copy of the investigative report within five days of the incident.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described.
Failure to Provide and Document Hydration for G-Tube Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on a gastrostomy tube (G-tube) for nutrition and hydration, and had an order for nothing by mouth (NPO), did not receive appropriate hydration management during their stay. The resident was identified as being at risk for dehydration, with a high score on the Dehydration Risk Screener. Despite this, there was no physician's order for water hydration or flushes, and no documentation that hydration was provided. The Registered Dietician (RD) recommended water flushes of 150 cc every six hours, but this recommendation was not communicated to the physician, not documented in the clinical record, and not implemented by nursing staff. The facility's staff, including the Licensed Vocational Nurse (LVN), Certified Dietary Manager (CDM), and RD, failed to ensure that the RD's hydration recommendation was followed. The LVN did not obtain a physician's order for water flushes, and both the LVN and CDM failed to document the RD's recommendation. The RD did not follow up within the expected timeframe to confirm that her recommendation was implemented. Additionally, the facility did not monitor or record the resident's intake and output (I&O) as required by facility policy for residents with feeding tubes. As a result of these failures, the resident did not receive documented water hydration during their five-day stay and was subsequently transferred to an acute care hospital with diagnoses of sepsis, hypernatremia, and severe dehydration. Facility policies required assessment and implementation of nutrition and hydration programs, as well as monitoring of I&O for residents receiving enteral feedings, but these were not followed in this case.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Identify and Address Non-Functional Restroom Call Lights
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, document, and correct a deficiency related to the physical environment, specifically the non-functional resident restroom call light system. During interviews and record reviews, it was revealed that the Medical Director, who participated in the QA committee, was unaware of any restroom call light deficits, despite acknowledging that nonfunctional call lights posed a safety concern. The facility's assessment tool and QAPI binder did not reflect any issues with the call light system, and there was no documentation indicating that the restroom call lights were not working. The Administrator confirmed that there was no record of the restroom call lights being nonfunctional, and the Maintenance Supervisor stated that there was no documentation of call light checks and was unaware of the issue. The facility's assessment tool and quality assurance policy both referenced the importance of maintaining the physical environment and communication systems, including call lights, for resident safety. However, the lack of monitoring and documentation led to the ongoing deficiency, affecting all 85 residents in the facility.
Non-Functioning Call Light Systems in Resident Bathrooms and Shower Rooms
Penalty
Summary
The facility failed to ensure that operational call light systems were available and accessible in all resident bathrooms and shower rooms. During an observation and interview with the Maintenance Supervisor, it was found that none of the bathroom call light systems in the facility were functioning. When activated, the call lights in multiple resident bathrooms and shower rooms did not trigger any visual or auditory alarms outside the rooms or at the nurse's station. In some cases, call lights were not accessible to residents using the toilet or shower, and in certain bathrooms and shower rooms, no call light system was present at all. Facility policy and procedure documents indicated that the Maintenance Department was responsible for maintaining all mechanical, electrical, and patient care equipment in safe operating condition, and that the facility was to provide a call system to enable residents to alert nursing staff from their rooms and toileting/bathing facilities. Despite these policies, the lack of functioning call light systems in 18 resident bathrooms and three shower rooms meant that all 85 residents potentially could not call for help if they required assistance while using these areas.
Failure to Secure Medication Carts and Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were securely stored and labeled in accordance with professional standards, as required by its own policy and procedure. During an early morning observation, Medication Cart 2 was found unattended and unlocked in a hallway near the nurse's station, with all drawers except the controlled medication drawer accessible. The Director of Nursing was present and able to open the unlocked drawers, and was unable to secure the cart's locking mechanism. The Director acknowledged that the unlocked cart could allow residents to access medications. In a separate incident, a registered nurse prepared medications for a resident, including Lactulose, and left the medication jar unattended on top of Medication Cart 1 while administering medications in a resident's room. The nurse later stated that she usually does not leave medications unattended on the cart. Review of the facility's policy confirmed that medications are to be stored safely and securely, accessible only to authorized personnel. These observations demonstrate a failure to follow established procedures for medication security.
Hand Hygiene and PPE Inventory Deficiencies
Penalty
Summary
Three dietary staff members failed to follow proper handwashing procedures as outlined by CDC guidelines. Specifically, each staff member applied soap to their hands before wetting them under running water, contrary to the recommended sequence of wetting hands first, then applying soap, lathering, scrubbing for at least 20 seconds, rinsing, and drying. The facility's posted handwashing instructions and its written policy and procedure on hand hygiene did not align with CDC guidelines, omitting the correct order and steps for effective hand hygiene. These observations were confirmed during interviews and a review of the facility's policies. Additionally, the facility did not maintain a written inventory of its personal protective equipment (PPE) such as gowns, gloves, masks, goggles, and face shields. Instead, the Supplies Supervisor monitored PPE stock visually and ordered more supplies when it appeared that inventory was running low. The facility's policy stated that appropriate PPE should be available at all times, but there was no documentation or record-keeping to ensure this requirement was consistently met.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 23 out of 34 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined by a review of the Client Accommodations Analysis and the Resident List Report. Specific room measurements and resident assignments showed that several rooms provided less than the required space per resident, with some rooms offering as little as 66 to 77 square feet per resident in double occupancy, and 70 to 75 square feet per resident in triple occupancy. The Administrator confirmed during an interview that these rooms did not meet the 80 square feet per resident requirement. No residents in the affected rooms were identified as having experienced negative effects due to the insufficient room size at the time of the survey. The facility's policy and procedure for Maintenance Services indicated that the Maintenance Department is responsible for maintaining the building in compliance with federal, state, and local regulations, but the documented room sizes and resident assignments did not meet these regulatory requirements.
Failure to Notify Responsible Party of Diet Change
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident's diet texture was changed from regular to pureed. The responsible party became aware of the change only after the resident mentioned over the phone that she was being fed 'baby food.' The Director of Nursing (DON) confirmed that the resident had requested a pureed diet after observing another resident eating it, and that nurses were permitted to downgrade diet consistency without informing the physician. However, there was no documentation in the nurse's notes indicating that the responsible party had been informed of this change. A review of the resident's physician orders showed that the prescribed diet was regular with thin consistency, and the progress notes documented the change to pureed. The facility's policy required timely notification of residents, families, legal representatives, and physicians regarding changes in a resident's condition. Despite this policy, the responsible party was not informed of the change in diet consistency, as confirmed by the DON.
Failure to Complete Required Assessments for Dialysis Residents
Penalty
Summary
The facility failed to complete required nursing assessments for two residents receiving dialysis services. For one resident, the Nursing Dialysis Communication Record (NDCR) showed that a pain assessment was not performed after dialysis, which was confirmed by a registered nurse who stated that such an assessment was important for early identification of complications. For the second resident, the NDCR indicated that a respiratory assessment was not completed before dialysis, and a pain assessment was not performed after dialysis. The registered nurse acknowledged that these assessments should have been conducted as part of the resident's care. Review of the facility's policy and procedure for dialysis care revealed that the facility is responsible for monitoring residents before and after each dialysis treatment and for maintaining all related documentation in the medical record. The Director of Nursing confirmed that the policy was not followed in these instances, resulting in incomplete assessments and documentation for both residents who required dialysis services.
Lack of Air Gap in Kitchen Food Preparation Sink
Penalty
Summary
The facility failed to ensure that the two compartment sink in the kitchen, which was used for washing produce and food for residents, was equipped with an air gap as required for backflow prevention. During multiple observations, it was noted that the sink lacked an air gap, and dietary staff were seen washing fresh strawberries in this sink. Both the Consultant Dietary Services Manager and the Director of Maintenance confirmed during interviews that the sink did not have an air gap, and the Director of Maintenance stated that it was not possible to create one in the current setup. Additionally, the facility did not have a policy or procedure addressing air gaps for sinks used in food preparation. A review of the FDA Food Code and the facility's own maintenance policy highlighted the requirement for backflow prevention devices such as air gaps to prevent contamination of the water supply. The absence of an air gap in the food preparation sink created a situation where contaminated water could potentially flow back into the clean water supply, posing a risk to food safety. The deficiency was identified through direct observation, staff interviews, and review of relevant policies and regulations.
Failure to Implement Fall Risk Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents who were at high risk for falls, leading to potential accidents and injuries. Resident 1's Fall Risk Assessment (FRA) dated 11/28/24 indicated a high fall risk score of 45, yet no fall risk care plan was noted in the clinical record. The Director of Nursing (DON) confirmed the absence of a fall risk care plan for Resident 1 during a review of the FRA. Resident 2's FRA dated 4/3/24 showed a high fall risk score of 60. Despite this, Resident 2 experienced two falls, on 6/21/24 and 7/12/24, resulting in injuries such as an abrasion on the mid-back, bruising to the left thumb, and a skin tear on the right lower arm. The DON confirmed that a fall risk care plan was only initiated on 7/15/24, after these incidents. The facility's policy requires the development of individualized care plans based on fall risk assessments, which was not adhered to in these cases.
Failure to Notify MDs and RP of Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program policy and procedure when it did not notify the medical doctors (MD) of two residents and the responsible party (RP) of one resident regarding allegations of abuse. Specifically, the Director of Nursing (DON) confirmed that there was no documentation indicating that the MDs of two residents and the RP of one resident were informed about the abuse allegations. This lack of documentation was acknowledged during a review of the residents' medical records and confirmed by the DON and the Administrator. The facility's policy, revised on January 31, 2020, mandates that the attending physician and responsible party, if applicable, be notified of any allegations and the outcome of the investigation. However, the facility did not adhere to this policy, as evidenced by the absence of documentation in the medical records of the involved residents. The Administrator confirmed that such notifications should be documented in a progress note, but this was not done, leading to a deficiency in the facility's abuse prevention and reporting procedures.
Inconsistent Implementation of Care Plans for Residents
Penalty
Summary
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. An interview with the Director of Nursing (DON) revealed that management received an email from a former employee alleging abuse against three residents. Registered Nurse (RN) 1 stated that for allegations of abuse, a care plan for delayed injury and psychosocial outcomes would be created and monitored for 72 hours. However, upon reviewing the care plans for two residents, it was found that the intervention to monitor psychosocial well-being for 72 hours was not consistently documented. The care plans for the residents were initiated following alleged incidents of physical abuse and neglect. Despite the facility's policy and procedure indicating that care plans should address medical, nursing, mental, and psychosocial needs, the documentation of psychosocial monitoring was inconsistent. The DON confirmed during a record review that the required monitoring was not documented consistently over the 72-hour period for the two residents involved.
Lack of Private Telephone Access for Residents
Penalty
Summary
The facility failed to provide reasonable access to a telephone that ensured privacy for three sampled residents. Interviews with staff and residents revealed that residents had to use the phone in the Administrator's office, the facility main office phone, or the nursing station, none of which provided privacy. The facility lacked portable phones, making it difficult for residents to have private conversations. This issue was confirmed by multiple staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, who acknowledged the lack of private phone access for residents. Resident 1, who was cognitively intact, expressed concerns about the inability to have private conversations. Resident 2, with moderate cognitive impairment, also confirmed the lack of privacy for phone calls. The Administrator in Training admitted that the facility had no portable phones since June 2023, and calls were either made at the nursing station or through staff members' cell phones. The facility's policy on telephone access, dated November 1, 2017, stated that residents should have access to private phone lines, but this was not being followed.
Failure to Implement Pressure Ulcer Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for a resident who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and reduced mobility. Upon admission, the resident was not assessed for the risk of developing pressure injuries as the Braden Scale for Predicting Pressure Sore Risk was left blank. This oversight was confirmed by the Director of Nursing (DON) during a record review. Additionally, the resident's left heel redness, noted one day after admission, was not reported to the physician, and no treatment was documented in the Treatment Administration Record (TAR). The DON confirmed that the physician was not notified to obtain treatment for the left heel redness. Furthermore, the facility did not develop a care plan to address the resident's left heel redness, as confirmed by the DON during a record review. The resident's condition worsened over time, with the left heel redness progressing to a suspected deep tissue injury (SDTI) and eventually to a Stage 3 pressure injury. The resident reported that the wound care provider had been treating the wound, which prevented the resident from being discharged. The Treatment Nurse (TN) stated that the facility's process for new admissions with wounds was not followed, as the necessary steps such as measuring the wounds, contacting the physician, developing a care plan, and performing weekly wound assessments were not completed. Additionally, the facility failed to conduct an interdisciplinary team (IDT) meeting to address the resident's left heel redness. The DON confirmed that no IDT meeting was held in March 2024 to discuss the resident's condition. The facility's policy and procedure for pressure ulcer prevention, which includes risk identification, assessment, care planning, and ongoing monitoring, were not adhered to, resulting in the resident developing a Stage 3 pressure injury to the left heel.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one of the three sampled residents. During an interview and record review, the Director of Nursing (DON) confirmed that the medical record for a resident contained inaccurate information. Specifically, the Wound Weekly Observation Tool (WWOT) dated 4/4/24 indicated that the resident had a suspected deep tissue injury (SDTI) to the left heel, while the care plan incorrectly documented it as a stage 3 pressure injury. The care plan was initiated on 4/4/24, but the interventions were noted to have started on 4/3/24, one day before the care plan initiation. The DON acknowledged that the documentation was not accurate. The facility's policy and procedure (P&P) on Completion & Correction, revised on 5/1/19, mandates that medical records should be completed and corrected in a standardized manner to ensure the highest quality and accuracy in documentation. The P&P specifies that entries should be recorded promptly, be complete, legible, descriptive, and accurate, and should follow a chronological sequence. The policy also states that events should never be documented before they occur. The failure to adhere to these guidelines resulted in the inaccurate documentation of the resident's medical condition.
Failure to Notify APS for Resident Leaving AMA
Penalty
Summary
The facility failed to follow their policy and procedure on contacting Adult Protective Services (APS) when a resident left the facility against medical advice (AMA). The resident, who had a diagnosis of metabolic encephalopathy, muscle weakness, alcohol abuse and withdrawal, hemiparesis/hemiplegia, noncompliance with medication, and end-stage renal disease, signed himself out of the facility. Despite the resident's moderate cognitive impairment and periods of confusion, as indicated by his Minimum Data Set (MDS) and History and Physical Examination (H&P), the facility did not notify APS as required by their policy. The resident was not his own responsible party, contrary to the administrator's initial statement, and arrangements for his continued dialysis were not made. The Social Services Director (SSD) confirmed that attempts to contact the resident's family member, who was listed as the responsible party and emergency contact, were unsuccessful. The SSD also confirmed that APS was not notified of the resident's AMA discharge, which was a violation of the facility's policy and procedure titled 'Discharge Against Medical Advice.'
Failure to Ensure Safe Air Mattress Settings
Penalty
Summary
The facility failed to ensure that air mattresses for three residents were in safe operating condition. During observations and interviews, it was found that the air mattress settings for Resident 1, Resident 2, and Resident 3 were incorrectly set at 290 lbs, 350 lbs, and 1000 lbs, respectively, despite their actual weights being 110 lbs, 158 lbs, and 448 lbs. Licensed Vocational Nurse (LVN) 1 and the Treatment Nurse (TN) were unaware of how to properly set up the air mattresses, and the Facility Maintenance Worker (FMW) believed that the nurses were responsible for setting the correct settings. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that no training had been provided to the nurses on how to set up the air mattresses according to resident weight. The lack of training and clear responsibility for setting up air mattresses led to improper settings that could potentially harm the residents. The facility's Licensed Nurse List indicated that none of the 28 nurses had received training on air mattress setup. Additionally, the facility did not have any policies or procedures in place for licensed nurse training and competencies related to air mattress settings. This deficiency in training and policy had the potential to impact the safety and well-being of the residents using air mattresses for pressure relief and wound prevention.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide oxygen per physician's orders for one of three sampled residents. During an observation and interview, a Licensed Vocational Nurse (LVN) noted that a resident was receiving oxygen at six liters per minute via nasal cannula, while the physician's order specified two liters per minute. The resident had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and respiratory failure. The facility's policy and procedure for oxygen administration required checking the physician's order and setting the oxygen at the prescribed rate, which was not followed in this instance.
Neglect of Foot Care for Two Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, resulting in pain, discomfort, and neglect. Licensed Vocational Nurses (LVNs) did not perform adequate skin assessments, develop care plans for foot conditions, or notify the attending physician about the residents' foot conditions. Certified Nursing Assistants (CNAs) also failed to report and document their observations of the residents' feet. The podiatrist did not provide appropriate medical foot care and treatment, as evidenced by the condition of the residents' feet during observations and interviews. Resident 15, an elderly male with multiple diagnoses including Type 2 Diabetes Mellitus with Polyneuropathy and Hemiplegia, had severely neglected feet. Observations revealed foot drop, wounds, redness, swelling, dry and scaly skin, and fungal infections. Despite these conditions, the resident's feet had not been properly cleaned or assessed for months. The podiatrist's last visit did not result in adequate treatment, and the resident's care plan did not address his foot issues. Weekly assessments by LVNs were found to be incomplete and often copied and pasted without proper evaluation. Resident 36 also suffered from neglected foot care. The resident had thickened, discolored toenails and dry, flaky skin, causing discomfort. Despite a physician's order for podiatry care, the resident had not received any treatment since the last documented visit several months prior. The facility's policies on grooming and showering were not followed, as changes in the residents' skin and nails were not reported to the attending physician or documented in their care plans.
Failure to Complete Activity Assessments
Penalty
Summary
The facility failed to ensure activity assessments were completed for 16 of 16 sampled residents. During interviews and record reviews, it was found that none of the residents had their activity assessments completed within the required seven days of admission. The Activity Director (AD) confirmed that the assessments were not done for residents admitted on various dates, ranging from February to March 2024. The AD acknowledged that the purpose of the activity assessment is to determine the best activities for each resident to improve their mental health, and this was not achieved due to the lack of timely assessments. The facility's policy and procedure, dated 2021, mandates that an activity assessment should be completed within seven days of a resident's admission to develop an individualized care plan. However, the review revealed that this policy was not followed for any of the sampled residents. The AD admitted that the assessments were not completed as required, which could potentially impact the residents' physical, mental, and psychosocial well-being. The failure to conduct these assessments as per the facility's policy was a significant oversight in the care provided to the residents.
Failure to Ensure Staff Competencies
Penalty
Summary
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. During interviews, it was revealed that a Certified Wound Nurse did not receive on-the-job training and had to figure out the computerized medical record system independently. The Director of Nursing admitted that while there used to be a competency checklist, it was currently unavailable as it was being updated, and no competency assessments were being conducted. The Director of Staff Development confirmed that there were no skills competency assessments documented for any of the licensed nurses. Additionally, the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff. A review of the facility's Policy and Procedure on On-the-Job Training indicated that training programs should be conducted to assist employees in performing their tasks, starting from the first day of employment and continuing until the department director is satisfied with the employee's performance. However, the lack of documented competency assessments and performance evaluations for the nursing staff indicates a failure to adhere to this policy, potentially resulting in harm to residents.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, properly store and label food, ensure employees followed the dress code policy, and serve food in a sanitary manner. During an observation, a dirty ladder and scaffolding with paint supplies were found in the kitchen, and the Maintenance Supervisor admitted to not removing them after completing ceiling repairs. Additionally, food items in the freezers and dry storage were found unsealed and without proper labeling, which was confirmed by the Certified Dietary Manager. The facility's policy required all food items to be labeled and dated, but this was not followed. Two staff members, including the Dietary Supervisor and a cook, were observed with uncovered facial hair, contrary to the facility's dress code policy. Furthermore, the Dietary Supervisor was seen returning a plated portion of turkey breast to the tray serving line, which was acknowledged as inappropriate by both the supervisor and the Registered Dietitian. These actions and inactions had the potential to spread foodborne illnesses throughout the facility, affecting all 71 sampled residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices for four sampled residents, leading to potential transmission of infectious diseases. For instance, a treatment nurse did not wear a gown while attending to a resident with MRSA, and another nurse did not perform hand hygiene before applying a clean dressing to a resident with bowel movement smears. Additionally, a resident with an ostomy had bowel movement leakage while eating, which was not addressed promptly, violating the facility's hygiene policy. Staff also failed to implement proper infection control practices for handling trash, transmission-based precautions, and laundry services. A CNA and a housekeeper were observed not performing hand hygiene after disposing of trash, and a laundry aide did not perform hand hygiene after sorting soiled linens. The infection preventionist admitted that the isolation cart was not fully stocked with necessary PPE, and there was no hand sanitizer available outside a resident's room. The facility did not conduct effective infection prevention surveillance activities. The infection preventionist admitted to not having records of hand hygiene monitoring and relied solely on visual observation. There were no indicators for surveillance, no data collection, and no analysis of surveillance activities. Additionally, the infection control committee meetings were conducted casually without proper documentation, and the infection preventionist could not provide meeting minutes.
Failure to Maintain Accurate Vaccination Records
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist (IP) maintained accurate records of Influenza and Pneumonia vaccinations for all current residents. During an interview and record review, it was found that 11 out of 71 current residents were not included in the immunization report, and the IP could not provide influenza vaccination records for these residents. Additionally, the IP was unable to verify the receipt or refusal of pneumonia vaccinations for 40 out of 71 residents. The IP confirmed that the facility census was 71, but only 60 residents were listed on the Immunization Report. Furthermore, only seven residents had signed declination statements for either the influenza or pneumonia vaccine, leaving a significant number of residents without documented consent or refusal for these vaccinations. The facility was unable to provide a policy and procedure related to influenza and pneumonia vaccinations when requested. According to the Centers for Disease Control (CDC) Guidelines, healthcare providers should incorporate immunization needs assessments into every clinical encounter, recommend needed vaccines, and maintain up-to-date records. The facility's failure to adhere to these guidelines and maintain proper vaccination records had the potential to compromise the health and well-being of the residents by not ensuring their immunity against certain infectious diseases.
Failure to Maintain Accurate Employee COVID-19 Vaccination Records
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) maintained an accurate record of employee COVID-19 vaccinations for 110 of 159 employees. During an interview and record review, it was revealed that the IP did not have a log of the employee COVID-19 vaccinations, either manually or electronically. The IP kept a binder with some employee vaccination cards but acknowledged that not all employees had provided proof of vaccination. The IP admitted to requesting the vaccination cards verbally but did not follow up to ensure compliance. At the time of the review, only 49 employee vaccination cards were on file out of 159 active employees. The facility's policy and procedure titled 'Infection Prevention and Control Program' indicated that the IP was responsible for monitoring the health status of all employees and ensuring they received necessary health screenings and vaccinations. However, the IP's failure to maintain accurate records and follow up on missing vaccination cards resulted in an incomplete employee COVID-19 vaccination record. This deficiency was identified during a concurrent interview and record review with the IP, highlighting a significant gap in the facility's infection prevention and control measures.
Failure to Train Staff on Behavioral Health Requirements
Penalty
Summary
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 sampled residents. During interviews and record reviews, it was revealed that no competency assessments were being conducted for any staff, and there was no documentation of training specific to psychological or mental disorders. The Director of Nursing confirmed the lack of competency assessments, and the Director of Staff Development confirmed the absence of behavioral health training for the nursing staff. The Administrator provided a Diagnosis Report indicating that the facility had residents with various psychiatric diagnoses, including anxiety disorder, major depressive disorder, schizophrenia, and psychosis. The Facility Assessment Tool indicated that the facility was equipped to manage psychiatric and mood disorders, but it also highlighted the necessity for staff training and competencies in caring for residents with mental and psychosocial disorders. Despite this, the facility had not provided the required training, leaving the staff unprepared to address the behavioral health needs of the residents. This deficiency had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that three of five sampled residents had their Minimum Data Set (MDS) assessments completed in a timely manner. Resident 43's Quarterly MDS assessment, dated 12/31/23, was completed on 3/20/24 but had not been transmitted. Resident 52's Quarterly MDS assessment, dated 12/29/23, was also not sent and was late. Resident 3's Annual MDS assessment, dated 1/24/24, was still in progress and had not been submitted. These delays were confirmed during interviews and record reviews with the MDS Coordinator. The facility's policy and procedures, dated 11/19, require comprehensive assessments of residents' needs to be conducted at intervals designated by OBRA and PPS requirements. Specifically, quarterly assessments must be conducted not less frequently than three months following the most recent OBRA assessment, and annual assessments must be conducted not less than once every twelve months. The failure to adhere to these timelines had the potential to result in unidentified health problems for the residents involved.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents in the facility. For Resident 15, the Medication Administration Record (MAR) indicated the use of Abilify, Oxcarbazepine, and Depakote for bipolar disorder and Seasonal Anxiety Disorder, but there was no record of MRR conducted for the last three months. Similarly, for Resident 55, the MAR indicated the use of Quetiapine Fumarate, Donazepil, Memantine, and Lorazepam for psychosis and unspecified dementia, but there was no record of MRR for the last three months. The Minimum Data Set Coordinator (MDSC) confirmed the absence of these reviews during interviews and record reviews. Additionally, the Director of Nursing (DON) confirmed that the Pharmacy Consultant had not reviewed the medication regimens for a significant number of residents over several months. The facility's Census Report and Medication Regimen Review Report indicated that a large number of residents' medication regimens were not reviewed by the pharmacist on multiple dates. The facility's policy and procedure stated that the consultant pharmacist should review each resident's medication regimen at least monthly, but this was not adhered to, as confirmed by the DON and the facility's records.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that two residents, Resident 15 and Resident 26, had access to a call light, which had the potential for unmet care needs. During an observation and interview, Resident 26 was found sitting on her bed without a visible call light. She pointed to the bed's remote control attached to the side rail as her means to call for help. A CNA later retrieved the call light from the floor and attached it to Resident 26's side rail, acknowledging that it should have been within her reach. Similarly, Resident 15 was unable to find his call light, which was hanging on the wall behind his headboard. An LVN confirmed that the call light should have been within Resident 15's reach. The facility's policy indicated that all residents should have a call system they can operate, and the call light should be within reach of the resident.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to follow their policy and procedure titled Notification of Responsible Party when the responsible party was not notified of a change of condition for one of four sampled residents. Resident 17 had a skin tear on their toe, and the Change in Condition Evaluation indicated that the resident had self-notified. However, the Treatment Nurse confirmed that Resident 17 did not have the capacity to make their own decisions, and the responsible party was never notified about the change in condition. The resident's History and Physical Examination also indicated that Resident 17 did not have the capacity to understand and make health care decisions. The responsible party last heard from the facility several months prior. The facility's policy requires that the responsible party be notified of any significant change in the resident's condition, which was not followed in this case.
Failure to Obtain Proper Authorization for Resident Transfer
Penalty
Summary
The facility failed to provide accurate transfer/discharge documents signed by the responsible party for a resident with severe cognitive impairment. Resident 55, an elderly female with diagnoses including unspecified dementia, anxiety disorder, and adult failure to thrive, was admitted with a BIMS score indicating severe cognitive impairment. Despite this, the Social Services Director (SSD) allowed Resident 55 to sign transfer documents, even though the resident's mental status was not stable, and a physician had certified that Resident 55 did not have the capacity to understand and make healthcare decisions. The SSD acknowledged being aware of the resident's cognitive limitations but still proceeded with the transfer arrangements without the proper authorization from the responsible party. During interviews, Resident 55's family member (FM 1) confirmed that Resident 55 had never signed any healthcare documents and was not capable of doing so. FM 1 stated that they were the one who signed all paperwork for Resident 55 and were not notified about the transfer documents being signed by the resident. The facility's policy and procedure required notifying the responsible party of any changes involving the resident's health, which was not followed in this case. The SSD admitted to not knowing who signed the documents for Resident 55, leading to confusion and potential risk for the resident's transfer process.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents, leading to potential negative outcomes. Resident 208 had multiple instances of refusing medical care, including hospital visits, blood sugar checks, medications, and dialysis. Despite these refusals and the complications they posed to his health, there was no specific care plan in place to address his noncompliance with care. The Director of Nursing (DON) acknowledged that there should have been specific care plans for Resident 208's issues, and the existing care plans were found to be vague and insufficient. Similarly, the facility failed to develop and implement a care plan for Resident 55 after a fall. The DON confirmed that there was no documented evidence of a care plan being created following the fall, which occurred on 3/12/24. The facility's policy and procedure for managing falls require that possible causes be identified within 24 hours and pertinent interventions be implemented to prevent subsequent falls. However, this protocol was not followed for Resident 55, indicating a lapse in the facility's adherence to its own policies.
Failure to Provide Preventive Measures and Weekly Wound Assessments
Penalty
Summary
The facility failed to provide preventive measures for pressure injuries for a resident diagnosed with quadriplegia, cellulitis of the buttocks, muscle wasting, and a history of Stage 2 pressure injury. Despite the resident's high risk for pressure ulcers, the facility did not provide a pressure-relieving mattress or appropriate padded dressings. The resident was observed with multiple pressure injuries, and staff acknowledged the lack of necessary preventive measures, such as a pressure-relieving mattress and protective devices for heels and ankles. The resident reported extended periods in a wheelchair and inadequate repositioning, contributing to skin breakdown. Additionally, the facility failed to ensure weekly wound assessments for two residents. For one resident, the last documented wound assessment was on 2/29/24, with no further assessments on 3/13/24, 3/20/24, and 3/27/24, despite the presence of multiple pressure injuries. The treatment nurse admitted to not completing the required weekly wound assessments and documentation. Another resident had a wound that started on 11/4/23 and reopened on 1/29/24, with no assessments documented between these dates to monitor the wound's progress. The facility's policies and procedures required weekly wound assessments and documentation, which were not followed. The Director of Nursing confirmed that weekly assessments should have been conducted for all wounds. The lack of adherence to these protocols resulted in the inability to monitor the healing progress of current wounds and potentially contributed to the development of additional pressure injuries.
Failure to Assess Bed Entrapment Risk for Residents
Penalty
Summary
The facility failed to ensure that five sampled residents were assessed for the risk of bed entrapment before the application of bedrails. During an observation and interview, it was found that the beds of these residents had quarter siderails up on each side, but no specific log or record of bed rail measurements was maintained. The Maintenance Supervisor acknowledged awareness of bed entrapment requirements but admitted that these had not been implemented at the facility yet. The Minimum Data Set Coordinator confirmed that the facility had not started assessing residents for bed entrapment risks, despite a recent discussion on the topic, and was unable to provide documentation for any of the five residents' bed entrapment risk assessments. The facility's policy and procedure on bed rails, dated 11/1/17, indicated that a Bed Rail Entrapment Risk Assessment should be completed by a licensed nurse before installing a bed rail. This includes assessing the resident for risk of entrapment and ensuring the bed's dimensions are appropriate for the resident's size and weight. However, the facility did not follow this policy, as evidenced by the lack of completed assessments and documentation for the five residents in question.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week. This deficiency was identified during an interview and record review with the Director of Nursing (DON) on 3/28/24 at 10:26 a.m. The review of the nursing staffing schedule for October, November, and December 2023 revealed multiple dates where no RN was on duty for the required eight hours. Specifically, the dates in question were 10/1/23, 10/2/23, 10/7/23, 10/8/23, 10/13/23, 10/14/23, 10/19/23, 10/20/23, 10/25/23, 10/26/23, 10/31/23, 11/1/23, 11/6/23, 11/12/23, 11/18/23, 11/19/23, 11/24/23, 11/25/23, 11/30/23, 12/1/23, 12/6/23, 12/7/23, 12/12/23, 12/13/23, 12/18/23, 12/19/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23. The facility's policy and procedure, dated 2006, required an adequate number of nursing personnel to meet resident needs, including having at least one RN in the facility at all times for facilities licensed for 60 to 99 beds, in addition to the DON.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that two residents, Resident 135 and Resident 44, were free from a medication error rate greater than five percent. Specifically, two medication errors occurred within 29 opportunities, resulting in a 6.9% error rate. During an observation, RN 1 did not administer Resident 135's Eliquis, a blood-thinning medication, because it was not available in the medication cart. Similarly, LVN 5 did not administer Resident 44's Trelegy Ellipta inhaler for COPD as it was also unavailable. Both nurses indicated they would contact the pharmacy to resolve the issue. A review of the Medication Administration Records (MAR) for both residents confirmed that the medications were not given as scheduled. The Director of Nursing (DON) stated that nurses are expected to call the pharmacy four or five days before running out of medication to prevent such occurrences. The facility's policy on medication administration allows for medications to be administered one hour before or after the scheduled time, but this protocol was not followed in these instances, leading to the observed deficiencies.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure the safe administration of medication for one resident when medications were found on the resident's bedside table. Specifically, an albuterol inhaler prescribed for the resident's Chronic Obstructive Pulmonary Disease (COPD) was observed on the bedside table during a survey. The resident's Order Summary Report indicated that the inhaler should be used every six hours for COPD management. However, the inhaler was not stored securely as required by the facility's policy and procedure for medication storage. During the observation, two Licensed Vocational Nurses (LVNs) acknowledged the presence of the inhaler on the bedside table. One LVN admitted that the inhaler should not have been left on the table, while the other LVN stated that they had forgotten the inhaler there accidentally. The facility's policy mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. The failure to adhere to this policy was evident in this incident, posing a risk of incorrect and unsafe medication administration.
Failure to Assess and Update Resident Food Preferences
Penalty
Summary
The facility failed to ensure dietary staff conducted an assessment of food preferences for Resident 56. During an interview, Resident 56 expressed dissatisfaction with the food served and stated that no one had discussed his food preferences with him. A review of Resident 56's dietary food card revealed that it had not been updated since his admission, despite the facility's policy requiring food preferences to be obtained as soon as possible and updated as needed. The Dietary Supervisor admitted responsibility for asking residents about their food likes and dislikes but had not seen Resident 56 since his admission. The Certified Dietary Manager confirmed that Resident 56's food preferences needed updating.
Failure to Serve Prescribed Pureed Diet
Penalty
Summary
The facility failed to ensure a pureed diet was served according to the physician's order for one resident. Resident 8, a [AGE] year-old female with a diagnosis of cerebral infarction, hemiplegia, hemiparesis, and dysphagia, was observed being fed a mechanical soft diet instead of the prescribed pureed diet with nectar thick liquids. This discrepancy was noted during an observation and interview with a Certified Nursing Assistant (CNA) and a Certified Dietary Manager (CDM), who admitted to giving the wrong diet to the resident. The facility's policy indicated that diet orders prescribed by the physician should be provided by the Food & Nutrition Services Department, which was not followed in this instance.
Failure to Provide Language-Assistance Service
Penalty
Summary
The facility failed to provide a language-assistance service for a resident who spoke a language native to the Punjab region of Pakistan. During an observation, the resident was seen trying to communicate with certified nursing assistants (CNAs) using body language and gestures, but they could not clearly understand each other. The CNAs admitted to using Google Translate to communicate with the resident, as the facility did not have a formal translation service. This lack of effective communication led to frustration for both the resident and the staff, as they struggled to understand the resident's needs. The Administrator-in-Training (AIT) acknowledged that there were two non-English speaking residents in the facility and that the staff assigned to these residents were supposed to speak their languages. However, the AIT admitted that the facility did not have a translation service and relied on calling staff at home or contacting the Ombudsman for social services for translation needs. The facility's policy indicated that qualified interpreters should be used, but this was not being followed. This failure had the potential for unmet care needs for the resident.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that four sampled residents received a summary of the Baseline Care Plan (BCP) within 48 hours of admission. Resident 15, who was readmitted after a recent hospitalization with diagnoses including Type 2 Diabetes Mellitus with Polyneuropathy and Hemiplegia, did not receive a complete BCP as sections for social services and rehabilitation services were incomplete. Additionally, there was no signature from Resident 15 or their representative indicating receipt of the BCP. Similarly, Resident 19, admitted with diagnoses including Metabolic Encephalopathy, Sepsis, and Altered Mental Status, did not have a signed BCP from their representative, despite brief assessments and plans of care being entered by various services. Resident 56, admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes Mellitus, and Mood Disorder, did not receive their BCP within 48 hours of admission, as it was completed three days later. Lastly, Resident 209's BCP was not completed at all, as confirmed by the Director of Nursing (DON). The facility's policy and procedure require that a baseline care plan be developed within 48 hours of admission to ensure immediate care needs are met, but this was not adhered to in these cases.
Failure to Administer Medication According to Physician's Order
Penalty
Summary
The facility failed to administer medication according to the physician's order for one of three sampled residents (Resident 209). During an interview and record review with the Director of Nursing (DON), it was confirmed that Percocet was administered to Resident 209 outside of the physician-ordered pain scale on five occasions. Specifically, Percocet was given for pain levels of 5 and 6, despite the order specifying it should only be administered for severe pain levels of 7-10. The facility's policy and procedure for administering medications, revised in April 2019, indicated that medications should be administered in accordance with prescriber orders, including any required time frames. The DON acknowledged that nurses should follow the order and contact the physician if adjustments need to be made.
Failure to Notify MD and Conduct IDT Meetings for Resident's Condition Changes
Penalty
Summary
The facility failed to notify a Medical Doctor (MD) of a significant change in a resident's condition and did not conduct an Interdisciplinary Team (IDT) meeting for the same resident. Resident 208 had an extremely high blood pressure reading of 240/110 despite being given two medications to control it. The resident refused to be sent out for higher-level care, and there was no documentation that the MD was notified of this critical condition. The Director of Nursing (DON) confirmed that the MD should have been informed due to the potential complications that could arise from such a high blood pressure reading. Additionally, the facility did not conduct IDT meetings for Resident 208's new wound issues on three separate occasions. The resident acquired a stage 4 pressure wound to the right thigh, skin abrasions to both middle fingers, and necrotic tissue on the right hand and left second toe. The Treatment Nurse (TN) confirmed that IDT meetings were not held for these wound issues, which should have been done to ensure all facility staff were aware of the resident's condition and the necessary care procedures. The facility's policy and procedure require prompt notification of the resident's MD and the coordination of care through IDT meetings for significant changes in a resident's condition, which was not followed in this case.
Failure to Complete Fall Risk Assessments
Penalty
Summary
The facility failed to complete a fall risk assessment for two of three sampled residents, Resident 209 and Resident 55. Resident 209 was admitted with diagnoses including lack of coordination, muscle wasting, reduced mobility, and need for assistance with personal care, but did not have a fall risk assessment completed on admission. The Director of Nursing (DON) confirmed this omission during a review of Resident 209's medical record. Additionally, Resident 55 experienced a fall on 3/12/24, but the last fall risk assessment for this resident was completed on 10/5/23. The DON confirmed that no quarterly fall risk assessment or post-fall risk assessment was conducted for Resident 55. The facility's policy and procedure on the assessment and management of resident falls stipulates that fall risk assessments should be completed on admission, quarterly, and after a fall, which was not adhered to in these cases.
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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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