Valley Palms Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in N Hollywood, California.
- Location
- 13400 Sherman Way, N Hollywood, California 91605
- CMS Provider Number
- 055287
- Inspections on file
- 54
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Valley Palms Care Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse investigation policy by not timely interviewing a CNA who directly witnessed and responded to a physical altercation between two residents with cognitive impairments and significant medical conditions, including DM, HTN, prior rib fractures, and post-stroke sequelae. Documentation and staff interviews showed that one resident reported the other repeatedly entering his room, leading to a verbal dispute and a physical encounter involving a raised front-wheel walker, a fall against a wall, and a skin tear, while the other resident reported becoming tangled with the walker and accidentally striking the first resident. A housekeeper and the CNA both observed the confrontation and intervened, with the CNA assisting the resident to bed and serving as translator when an RN assessed him. Despite a written policy requiring interviews of all witnesses and involved staff, the DON did not initially recognize the CNA as a witness, did not obtain a written statement from her during the investigation, and only interviewed her several days later, acknowledging that the abuse policy was not followed.
A resident with multiple comorbidities and cognitive impairment developed a right forearm skin tear and left cheek abrasion after an altercation with another resident that led to a loss of balance and impact with a wall. The Treatment Nurse identified the new skin tear and abrasion but did not measure the wound, despite acknowledging that new skin changes should be measured to monitor progress. The DON confirmed that the lack of wound measurements left the medical record incomplete and was not consistent with the facility’s wound care and injury investigation P&Ps, which require documentation of wound size and detailed, objective descriptions of injuries.
A resident with moderate cognitive impairment was physically struck on the left cheek by another resident with severe cognitive impairment and a history of aggressive behavior. The incident occurred in a hallway and was witnessed by multiple staff, who confirmed that the aggressor reached out, grabbed the victim's arm, and punched her. Facility policy states residents must be free from abuse, and staff interviews and documentation confirmed the event as physical abuse.
A resident with rib fractures and heart disease experienced severe pain, as documented by staff and self-reported by the resident. Despite a physician's order for hydrocodone-acetaminophen for pain rated 4-10, there was no documentation that the medication was given when the resident reported a pain level of eight. Facility leadership confirmed the medication should have been administered as ordered.
A nurse administered sacubitril-valsartan to a resident with heart failure even though the resident's blood pressure was below the physician-ordered threshold for holding the medication. The medication was given despite clear instructions to withhold it for systolic blood pressure under 110 mmHg, as confirmed by documentation and nursing leadership interviews.
A resident with intact cognitive function and multiple health conditions reported to staff that her roommate had hit her legs. The allegation was communicated to a CNA, LVN, and RN, but was not reported to the Administrator or authorities as required by facility policy. Staff delayed reporting because they believed the accused resident was not capable of abuse, resulting in a delayed investigation and intervention.
A resident with multiple chronic conditions reported being physically abused by a roommate, but staff did not perform a body assessment or notify the physician as required by facility policy. Nursing staff and the DON later confirmed that these actions should have been taken immediately following the allegation, but were not completed, resulting in delayed care and monitoring.
A resident with a urostomy was not provided care in accordance with professional standards, as staff failed to notify the physician about cloudy urine with sediments, did not assess or document signs of UTI as required by the care plan, and did not record urine output in milliliters per physician order. These actions were confirmed by interviews and record reviews, revealing lapses in communication and documentation among nursing staff.
A resident with significant medical needs, including a urinary catheter, was observed with an uncovered urinary collection bag. Staff interviews revealed the cover was removed during care and not replaced, despite facility policy requiring dignity covers for such devices. Multiple staff acknowledged the oversight and its potential impact on the resident's psychosocial wellbeing.
A resident with a urostomy and complex medical history had cloudy urine with sediments observed by staff, but the CNA did not report these findings to the LVN as required by the care plan. The LVN only learned of the issue later and confirmed that such symptoms should have been reported to the physician. Facility leadership acknowledged that the care plan was not followed, resulting in a failure to provide timely notification to the physician about potential signs of UTI.
A resident with an indwelling urinary catheter did not have a dignity bag covering the catheter drainage bag, as required by the facility's policy. This was observed during a review and interview, where it was noted that the bag was exposed, potentially affecting the resident's sense of self-worth. The resident's care plan included an intervention to ensure the bag was covered, but it was not in place during the observation. The DON confirmed the necessity of the dignity bag for privacy.
A resident with an indwelling urinary catheter did not receive proper care as the catheter drainage bag was found touching the floor, contrary to the care plan and facility policy. Staff interviews confirmed the oversight, and the DON acknowledged the failure to prevent potential infection risks.
A facility failed to notify a resident's MD and family when a urinalysis was not collected, leading to delayed care for a UTI. Despite multiple attempts, the sample was not obtained due to the resident's noncompliance, and the facility did not follow its policy to inform the MD after two refusals. The resident was later diagnosed with a UTI at a hospital.
A resident with a history of dementia and UTI did not receive a physician-ordered urinalysis and culture, leading to a delay in care. Despite exhibiting symptoms of a UTI, the facility failed to complete the necessary tests, and there was a lack of documentation and follow-up. The resident was later diagnosed with a UTI at a hospital, highlighting the facility's failure to adhere to testing protocols.
A resident on a puree diet was served bread that was too sticky and did not pass the spoon tilt test, indicating a failure to meet IDDSI Level Four standards. The staff member responsible did not follow the recipe, relying instead on estimation, leading to non-compliance with the required food texture and consistency.
A resident with dysphagia was served a biscuit instead of a mechanical soft finely chopped diet, leading to signs of distress during feeding. The RN did not review the correct discharge instructions, resulting in an incorrect diet order. Staff lacked training on the IDDSI framework, contributing to the deficiency.
The facility failed to maintain the dignity and privacy of three residents. A resident with multiple sclerosis was inadequately covered during transport, exposing his sides. Another resident with diabetes and dementia was left with her gown unsecured, exposing her back and side. A third resident with cerebral infarction was not dressed in her own clothing while in a wheelchair. These incidents highlight deficiencies in ensuring resident dignity and privacy.
The facility failed to provide adequate pressure ulcer care for three residents. One resident was not given a low air loss mattress (LALM) upon admission with a Stage 4 pressure injury, and no baseline care plan was developed. Two other residents had their LALMs turned off due to unavailable outlets, risking further skin breakdown. These actions were contrary to the facility's policies, placing the residents at risk for worsening conditions.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, as required by their policy. The resident, dependent on staff for mobility, had missing documentation for vital signs and access site condition on multiple occasions. The DON confirmed the importance of this documentation to monitor potential side effects and ensure stability post-dialysis.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies related to medication administration and storage. LVNs did not administer prescribed medications to two residents, despite marking them as given in the MAR. Additionally, a controlled substance was not properly documented, and a resident received medication without required vital checks. Expired medications were found in a cart, and an emergency kit was not replaced timely, indicating lapses in medication management.
The facility did not follow the prescribed breakfast menu for 88 residents, serving scrambled eggs instead of the planned omelet. This deviation was confirmed by staff interviews and a review of the facility's policies, which require adherence to menus to meet residents' nutritional needs.
A facility failed to follow its established menu, affecting 88 residents when scrambled eggs were served instead of the planned breakfast omelet. This deviation was confirmed through interviews and record reviews, with the Dietary Supervisor acknowledging the mistake. The facility's policies require adherence to menus developed to meet nutritional needs, which was not followed in this instance.
The facility failed to ensure safe food storage and preparation practices, with resident foods not labeled and dated, and staff foods improperly stored in the kitchen refrigerator. Observations revealed undated containers of hummus, mashed potatoes, and cut oranges. Interviews confirmed awareness of the issue, and the facility's policies required all foods to be covered, labeled, and dated, posing a risk to 88 of 92 medically compromised residents.
A LTC facility failed to maintain an effective infection control program, as observed in several deficiencies. An LVN did not follow Enhanced Barrier Precautions while administering medications via a G-tube, and personal items were improperly stored in medication areas. Additionally, residents' respiratory equipment was not properly labeled or stored, increasing the risk of contamination. These actions were contrary to the facility's policies, as confirmed by the Infection Preventionist and DON.
A facility failed to obtain informed consent for a resident's use of lorazepam, a psychotropic medication prescribed for anxiety. Despite the resident's capacity to understand and make decisions, there was no documented evidence of informed consent, contrary to the facility's policy. Interviews revealed that the facility did not follow its procedures, and the resident confirmed that the possible side effects of the medication were not explained to her.
A resident with dementia and visual impairment was found without a reachable call light on multiple occasions, despite facility policies requiring it to be within reach. Staff acknowledged the oversight, and the DON confirmed the importance of call light accessibility for resident safety and communication.
A facility failed to create a comprehensive care plan for a resident with dementia and muscle weakness, who exhibited screaming behavior. Despite the resident's need for assistance with daily activities and observed screaming for help, no care plan addressed this behavior. Staff confirmed the absence of a care plan, and the DON acknowledged the oversight, which contradicted the facility's policy on person-centered care plans.
A resident with cerebral infarction and dementia, requiring assistance with eating, was left with an untouched breakfast tray, as CNA 9 failed to provide necessary help. The facility's policy mandates assistance for residents unable to feed themselves, which was not followed, risking the resident's nutritional health.
A facility failed to follow up on a lab draw for phenobarbital, a seizure medication, for a resident with epilepsy, anxiety disorder, and COPD. Despite physician orders and care plan requirements, the lab draw was not completed, and no results were documented. Interviews with the ADON and DON revealed lapses in the facility's process for ensuring lab draws, leading to a deficiency in resident-centered care.
Two residents in an LTC facility were exposed to safety hazards due to improper practices. One resident had an unstable overbed table placed on their floor mat, posing a fall risk, while another had trazodone pills left unattended at their bedside, contrary to facility policy. Both incidents involved staff failing to adhere to safety and medication administration protocols.
The facility failed to label the open date on a Senna container on Medication Cart 2, as observed during a survey. An LVN admitted to opening the container without labeling it, and the DON confirmed that medications should have an open date for proper tracking. The facility's policy requires medications to be stored properly and labeled, but this was not followed, resulting in a deficiency.
The facility failed to lock medication carts, as observed on a specific morning when Medication Cart B, the Middle Cart, and Treatment Cart B were left unlocked. This was confirmed by an LVN, an RN, and the DON, who emphasized the importance of locking carts to prevent unauthorized access and potential adverse effects. The facility's policy requires all compartments with drugs to be locked when not in use.
A resident with diabetes mellitus did not receive insulin as per the physician's sliding scale order on two occasions, despite blood sugar levels indicating the need for administration. The facility's policy requires medications to be administered according to prescribers' orders, which was not followed by the involved nursing staff.
A facility failed to maintain a homelike environment when a deceased resident was left in a shared room with two other residents for 13 hours. The deceased resident's body was not moved promptly, despite staff awareness, causing distress to the roommates. The facility's policy on providing a safe and comfortable environment was not followed, affecting the mental health of the residents involved.
The facility failed to provide necessary social services to two residents after their roommate's death, leaving the deceased in the shared room for 13 hours. This oversight potentially increased stress and anxiety for the residents, who were not evaluated for psychological issues. The facility's policies on maintaining a homelike environment and behavioral health services were not followed.
A resident with a history of pneumonia, COPD, and dementia experienced an elevated pulse rate, but the physician was not notified until several hours later, contrary to facility policy. The DON confirmed the delay, acknowledging that the physician should have been informed immediately to ensure timely medical intervention.
A facility failed to create a comprehensive care plan for a resident with tachycardia, despite the resident's complex medical conditions including pneumonia, COPD, and dementia. The resident's elevated pulse rates were recorded, and although a physician was notified and an ECG was ordered, no care plan was developed to guide staff in managing the condition. The Director of Nursing acknowledged the absence of a care plan, which was contrary to the facility's policy requiring measurable objectives and timetables for resident care.
A resident with hypertension was administered metoprolol tartrate despite having a systolic blood pressure below the physician-ordered threshold. The facility's policy requiring vital sign checks before medication administration was not followed, as confirmed by the DON.
A resident with significant medical needs was discharged to an unlicensed independent living facility instead of a board and care facility as per physician's order. The discharge process was compromised by poor communication and documentation, including the failure to inform the Placement Coordinator of the physician's order and the omission of the board and care facility's contact number in the medical record. Facility staff interviews highlighted a lack of verification and follow-up on the resident's chosen discharge location.
A resident's body remained uncollected for over 12 hours due to the facility's lack of a mortuary pick-up policy and contract. Staff were unsure of the procedures to follow, and the Administrator was not informed in a timely manner. The facility's governing body failed to establish and implement necessary management policies.
A resident with chronic conditions was discharged to an independent living facility without the contact number being documented in their medical record. Despite severe cognitive impairment, the resident was discharged according to a physician's order to a Board and Care facility, but the contact information was missing, leading to a lack of follow-up. Interviews revealed lapses in documentation and communication regarding the discharge process.
The facility failed to assess three residents for the risk of entrapment before installing bed rails. Residents with various medical conditions and histories of falls were found with quarter-length bed rails without prior assessments. Both the residents and staff confirmed the lack of assessments, and the DON acknowledged the oversight.
A resident with multiple health issues, including spine fusion and muscle weakness, was incorrectly assessed as not at risk for falls despite scoring a seven on the Fall Risk Assessment. This error, confirmed by both a Registered Nurse and the DON, led to potential inadequacies in the resident's care plan and fall prevention measures.
Failure to Interview Key Witness in Resident-to-Resident Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy and procedure by not thoroughly investigating an allegation of resident-to-resident physical abuse involving two residents. One resident, admitted with multiple right rib fractures, DM, and HTN, had an H&P indicating lack of capacity to understand and make decisions and an MDS showing moderately impaired cognitive skills. Progress notes and an SBAR documented that this resident reported another resident repeatedly entering his room, leading to an altercation in which he raised his walker in defense, lost his balance, hit the wall, and sustained a right forearm skin tear. The other resident, admitted with sequelae of cerebral infarction, generalized muscle weakness, and difficulty walking, had an H&P indicating capacity to make decisions but an MDS showing severely impaired cognitive skills, and his SBAR documented his account of a verbal altercation escalating when the first resident raised a front-wheel walker, resulting in him becoming tangled with the walker, being hit in the chest, and accidentally hitting the other resident in the face. Multiple staff accounts confirmed that an altercation occurred and that staff intervened. A housekeeper reported seeing the first resident holding his walker up in the air in front of the second resident and stated she separated them before the administrator entered the room. A CNA reported hearing the housekeeper scream for help, observing both residents trying to fight, seeing the first resident attempt to hit the second resident with his walker, and seeing the second resident with his right fist raised attempting to punch but not making contact. This CNA stated she remained in the room with the administrator, assisted the first resident to sit on the bed, and helped calm him. An RN later reported that when she responded to the room, the CNA was present beside the first resident, who was seated on the bed, and that she spoke with the first resident using the CNA as a translator. The facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy required that the individual conducting the investigation interview any witnesses to the incident and staff members on all shifts who had contact with the resident during the period of the alleged incident. The DON stated she was not aware that the CNA had responded to the incident and therefore did not initially interview the CNA or obtain a written statement, even though she had obtained statements from other staff including the housekeeper, RN, LVNs, and other CNAs. The DON acknowledged that the allegation between the two residents occurred on a specific date and that the CNA was not interviewed until several days later, that the abuse policy was not followed, and that it was important to interview all staff who were involved in the incident to verify what they observed.
Failure to Measure and Document New Skin Tear per Wound Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s skin condition was assessed and documented according to professional standards of practice and facility policy, resulting in an incomplete medical record. The resident was admitted with diagnoses including multiple right rib fractures, diabetes mellitus, and essential hypertension, and had documented cognitive impairment and lack of decision-making capacity. A skin assessment dated 2/5/2026 showed the resident had a right outer forearm skin tear and a left cheek abrasion following an altercation in which another resident entered the room, the resident raised a walker in defense, lost balance, and hit the wall. An SBAR communication form documented the incident and the resulting right forearm skin tear and left cheek abrasion. During interview, the Treatment Nurse stated he performed the skin check on 2/5/2026, noted the right forearm skin tear and left cheek abrasion with minimal bleeding, but did not measure the skin tear and acknowledged he does not measure skin issues all the time, despite stating that measurements should be done with any new skin changes to track improvement. The DON confirmed the Treatment Nurse should have measured the skin tear and that, without measurements, the facility would not know if the skin tear was getting better or worse or if treatment was effective, and that the medical record was incomplete and facility policy was not followed. Review of the facility’s Wound Care policy required that all assessment data, including wound size, be recorded, and the Investigating Resident Injuries policy required objective, sufficiently detailed descriptions, including dimensions of injuries, which were not documented in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck her on the left cheek while both were in the hallway. The incident occurred as one resident was wheeling herself in her wheelchair and was approached by another resident, who was being pushed by a CNA. The aggressor resident reached out, grabbed the victim's left arm, and punched her on the left cheek. Multiple staff members, including CNAs and nurses, witnessed or were immediately informed of the event, and documentation confirmed the physical contact and the resident's report of being hit. The resident who was struck had a history of transient cerebral ischemic attack, unspecified encephalopathy, and generalized muscle weakness. Her cognitive skills for daily decisions were moderately impaired, and she required moderate assistance for activities such as toileting and showering. The aggressor resident had diagnoses including metabolic encephalopathy, diabetes mellitus, and generalized muscle weakness, with severely impaired cognitive skills and no capacity to make decisions. Staff interviews and records indicated that the aggressor resident had a known history of aggressive behaviors, including previous incidents directed at staff. Facility policy and procedure documents, as reviewed with the Director of Nursing and other staff, clearly state that residents have the right to be free from abuse, including physical abuse by other residents. Staff interviews consistently identified the incident as abuse, regardless of the aggressor's cognitive status or the absence of physical injury. The event was substantiated by witness statements, resident reports, and facility documentation, confirming that the resident was not protected from physical abuse as required by facility policy.
Failure to Administer Ordered Pain Medication for Resident with Severe Pain
Penalty
Summary
A resident with multiple rib fractures, a history of falls, and hypertensive heart disease with heart failure was admitted to the facility and had a physician's order for hydrocodone-acetaminophen to be administered every four hours as needed for moderate to severe pain (pain level 4-10). The resident's Minimum Data Set indicated occasional pain at a level of six out of ten, and the Medication Administration Record documented a pain level of eight out of ten on a specific date. However, there was no documentation that the ordered pain medication was administered at that time. Interviews with the resident confirmed ongoing severe pain, particularly when being moved or turned, and that pain medication provided only short-term relief. The Assistant Director of Nursing and the Director of Nursing both acknowledged that the nurse should have administered the pain medication as ordered and that there was no documentation of administration or follow-up. Facility policies reviewed indicated that medications are to be administered according to prescriber orders and that pain should be addressed with appropriate interventions.
Failure to Follow Physician's Order for Blood Pressure Parameters in Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) administered sacubitril-valsartan to a resident despite a physician's order to hold the medication if the resident's systolic blood pressure (SBP) was below 110 mmHg. On the date in question, the resident's blood pressure was recorded at 109/77 mmHg, yet the medication was still given. The resident had a history of multiple rib fractures, falls, and hypertensive heart disease with heart failure. The medication order specifically instructed staff to withhold sacubitril-valsartan for SBP less than 110 mmHg or heart rate less than 60 beats per minute. Record reviews confirmed that the medication was administered contrary to the physician's order, and this was acknowledged by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. Facility policy required medications to be administered as prescribed, including verification of vital signs when necessary. Documentation in the Medication Administration Record (MAR) and progress notes indicated that the medication was given despite the resident's blood pressure being below the specified threshold.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
Facility staff failed to report an allegation of physical abuse in a timely manner after a resident, who had intact cognitive functioning and a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, reported being hit on the legs by her roommate. The incident was first disclosed by the resident to a Certified Nurse Assistant (CNA), who then informed a Licensed Vocational Nurse (LVN), and subsequently a Registered Nurse (RN). Despite the resident's clear statements to multiple staff members on the night of the incident, the allegation was not immediately reported to the facility's Administrator or to the required authorities as outlined in the facility's abuse reporting policy. Interviews with staff confirmed that the CNA, LVN, and RN were all made aware of the resident's claim that her roommate had hit her legs. The RN acknowledged that the resident's statement constituted an allegation of physical abuse and should have been reported immediately to the Administrator, who also served as the Abuse Coordinator. The Director of Nursing (DON) and the Administrator both stated that the facility's policy required immediate reporting of suspected abuse, defined as within two hours, but this protocol was not followed. Instead, the staff delayed reporting, and the investigation was not initiated until several days later when the resident informed the Administrator directly. Facility records and interviews revealed that staff did not report the allegation because they believed the accused resident was not capable of such behavior. This decision was made despite the facility's policy, which mandates reporting all suspicions of abuse regardless of staff assumptions. The failure to report the incident promptly resulted in a delay in investigation and intervention, as confirmed by the facility's own documentation and staff statements.
Failure to Assess and Notify Physician After Resident Abuse Allegation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who reported an allegation of physical abuse by another resident. On the evening of the incident, the resident informed a CNA that her roommate had hit her legs. The CNA relayed this information to an LVN, who then spoke with the resident and confirmed her complaint of pain in her legs. Despite this, there was no documentation that a body assessment was performed or that the physician was notified at the time of the allegation. Record reviews showed that the resident had a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, and was dependent on staff for several activities of daily living. The resident was cognitively intact and able to communicate her needs and experiences. The care plan and SBAR forms indicated that the resident was at risk for emotional distress related to the abuse allegation, but there was no evidence that an assessment or physician notification occurred immediately following the report of abuse. Interviews with nursing staff and the DON confirmed that facility policy required immediate assessment and physician notification in the event of an abuse allegation, which was not followed in this case. The facility's own investigative summary noted that staff failed to report the allegation because they believed the accused resident was not capable of such behavior. This failure to follow protocol resulted in a delay in care and monitoring for the resident who reported the abuse.
Failure to Notify Physician and Document Urostomy Care
Penalty
Summary
A deficiency occurred when a resident with a urostomy did not receive care consistent with professional standards, the care plan, and physician orders. The resident, who had multiple complex diagnoses including multiple sclerosis, bladder cancer, and a history of acute pyelonephritis, was observed to have cloudy urine with white sediments in the urinary tubing. Despite this, staff failed to notify the physician of these abnormal findings, as required by both the resident's care plan and facility policy. Certified Nursing Assistant (CNA) observed the cloudy urine but did not report it to the Licensed Vocational Nurse (LVN), and the LVN only became aware of the issue after being informed later. The Director of Nursing (DON) and other staff confirmed that the physician should have been notified immediately about the abnormal urine appearance. Additionally, the facility failed to assess, monitor, and document the resident for signs of urinary tract infection (UTI) as indicated in the care plan. The care plan specifically required monitoring for symptoms such as pain, burning, blood-tinged urine, cloudiness, changes in urine output, and other signs of infection. However, review of the resident's progress notes and other documentation revealed that there was no consistent monitoring or documentation of these signs and symptoms. The Director of Staff Development (DSD) acknowledged that nurses did not document assessments of urine color, odor, or presence of sediments every shift, as required by policy. Furthermore, the facility did not follow the physician's order to monitor and document the resident's urine output in milliliters (ml) every shift. Instead, documentation in the Medication Administration Record (MAR) only indicated the number of times the resident urinated, not the actual volume, which was contrary to the physician's explicit instructions. The DSD and DON both confirmed that this failure to document urine output in ml could result in unrecognized urine retention. Facility policy also required accurate measurement and documentation of input and output, which was not followed in this case.
Plan Of Correction
F 691 F 691a. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On 4/30/25, LVN 1 immediately called MD to notify him of Resident 1 urinary tubing sediments and cloudy urine. ADON placed an order in PCC for monitoring of foley catheter output for Resident 1 on 05/01/25. 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 ADON reviewed all other residents with foley catheter on 4/30/25 and noted no change of condition indicated, therefore, no notification to MD was required. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25 F 691 F 691. b&c How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice DON performed one-to-one in-service to LVN 1 on 4/30/25 regarding proper documentation of monitoring urine output in milliliters as well as documentation and proper assessment of the quality of the output. DON also reviewed the importance of following physician order. DON also reviewed facility policy and procedure "Urinary Catheter Care" with LVN 1 on 4/30/25. 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 ADON reviewed all other residents in the facility with foley catheter on 4/30/25 and found no other signs of UTI related to catheter care. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25
Failure to Maintain Resident Dignity by Not Covering Urinary Collection Bag
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's dignity by not ensuring the resident's urinary collection bag was covered with a privacy bag. The resident, who had multiple diagnoses including multiple sclerosis, bladder cancer, and acute pyelonephritis, required maximum assistance for daily activities and had a urinary catheter or urinary ostomy. During an observation, the urinary collection bag was found hanging on a bedside drawer handle without a dignity cover. Staff interviews confirmed that the cover had been removed during care and was not replaced, and that staff were aware the bag should be covered for privacy. The facility's policy required that urinary catheter bags be covered to promote resident dignity and self-esteem. Multiple staff members, including a CNA, LVN, and the DON, acknowledged that the urinary collection bag should have been covered and that its absence could affect the resident's psychosocial wellbeing. The failure to provide the dignity cover was confirmed through observation, staff interviews, and review of facility policy.
Plan Of Correction
Residents rights/Exercise of Rights How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1, on 04/30/2025, immediately placed a dignity bag on Resident 1's urinary collection bag. 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: Infection Control Nurse, on 4/30/25, completed a facility audit of all residents with foley catheter with dignity bag and found no other deficiencies noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 and LVN 1 regarding placement of dignity bag to cover resident urine collection bag; and facility policy and procedures for Dignity and Infection Control. DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding placement of dignity bag over residents' urine collection bags as well as the facility policies for Infection Control and Dignity. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Managers and staff will perform facility room rounds using the facility tool entitled "Resident Centered Care Room Rounds Report" Monday to Friday to verify all foley catheters' urine collection bags have a dignity bag in place. On weekends, the Manager of the Day or designee will perform these room rounds to verify all appropriate dignity bags are in place. The Director of Nursing will collect and review room rounds data weekly and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator will determine if continued auditing and monitoring are recommended after three months. Completion Date 5/22/25 F 550 F 550 Develop/Implement Comprehensive Care Plan
Failure to Implement Person-Centered Care Plan for Urostomy Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan for a resident with a urostomy, as required by federal regulations. The resident, who had diagnoses including multiple sclerosis, a malignant neoplasm of the bladder, and acute pyelonephritis, was admitted with a care plan intervention to monitor, record, and report signs and symptoms of urinary tract infection (UTI) to the physician. The care plan specifically listed symptoms such as cloudy urine, presence of sediments, and other indicators of infection that should prompt physician notification. On the day of the incident, observations revealed that the resident's urinary tubing contained cloudy urine with white sediments. The Assistant Director of Staff Development confirmed these findings and stated that the Certified Nursing Assistant (CNA) should have reported this to the Licensed Vocational Nurse (LVN). However, the CNA admitted to noticing the cloudy urine but did not report it to the LVN. The LVN only became aware of the issue after being informed later and acknowledged that such findings are possible signs of infection and should be reported to the physician without delay. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the care plan was not followed, as the physician was not notified about the abnormal urine findings. The facility's policy required that any abnormalities in urine output, such as sediments or changes in color, be reported to the physician. The failure to follow the care plan and notify the physician as required constituted the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 4/30/35, Treatment Nurse immediately replaced urostomy tubing and bag for Resident 1. The care plan was updated by LVN 1 on 4/30/25, and the physician was notified. 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: Infection Control Nurse on 4/30/25 completed a facility audit of all residents with Foley catheter to check for sedimentation and cloudiness in the output. Additionally, IP Nurse verified all care plans were in place for all residents with Foley catheter on 4/30/25. All residents with Foley Catheter have care plans in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 regarding prompt reporting of any cloudy urine or sediment present in the urinary tubing and catheter bag to the LVN. DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". DON performed licensed staff in-service to LVNs and RNs on 4/30/25, 5/1/25, and 5/2/25 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Medical records department to audit care plans weekly for three months for residents with Foley catheter, to ensure care plan is being followed. Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25
Failure to Provide Dignity Bag for Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received proper care and services by not providing a dignity bag to cover the catheter drainage bag. This oversight was observed during a record review and an interview with a Licensed Vocational Nurse, where it was noted that the resident's catheter drainage bag was exposed and lacked a dignity bag. The facility's policy and procedure on dignity, which was last reviewed in January 2025, mandates that urinary catheter bags should be covered to promote the resident's sense of well-being and self-esteem. The resident, admitted on February 25, 2025, had a diagnosis of cerebral infarction and was using a Foley catheter for urinary retention due to benign prostatic hyperplasia. The care plan for the resident, initiated on February 26, 2025, included an intervention to ensure the catheter drainage bag was covered. However, during an interview, a Certified Nursing Assistant mentioned that the dignity bag was present before a lunch break, but it was not in place during the observation. The Director of Nursing confirmed that the dignity bag should have been used to protect the resident's privacy, as its absence could negatively impact the resident's psychosocial well-being.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency. The resident, admitted with a diagnosis of cerebral infarction and benign prostatic hyperplasia, had a physician's order for a Foley catheter and required catheter care every shift. The care plan specifically indicated that the catheter bag should not touch the floor to prevent urinary tract infections (UTIs). However, during an observation, the resident's catheter drainage bag was found touching the floor, contrary to the care plan and facility policy. Interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, confirmed that the catheter bag was not placed in a basin, which is necessary to prevent contact with the floor and potential infection. The Director of Nursing acknowledged the failure to adhere to the facility's policy, which mandates keeping the catheter tubing and drainage bag off the floor to prevent UTIs. This oversight had the potential to cause complications for the resident, including discomfort and infection.
Failure to Notify MD and Family of Uncollected Urinalysis
Penalty
Summary
The facility failed to adhere to its Policy and Procedures regarding notifying the medical doctor and family member about a change in a resident's condition. Specifically, the facility did not inform the medical doctor (MD 1) and family member (FM 1) that a urinalysis with culture and sensitivity test was not collected for Resident 1. This oversight resulted in a delay in the delivery of care and services to Resident 1, who was diagnosed with a urinary tract infection (UTI). Resident 1 was admitted to the facility with multiple diagnoses, including dementia, UTI, hemiplegia, and hemiparesis following a cerebral infarction. The care plan for Resident 1 included monitoring for signs and symptoms of UTI. Despite physician orders for a urinalysis and culture, the facility did not collect the required samples. The resident's Minimum Data Set indicated that Resident 1 was always incontinent, and the SBAR noted physical aggression, leading to new orders for various tests, including the urinalysis. Interviews with staff revealed that attempts to collect the urinalysis were unsuccessful due to Resident 1's noncompliance. The Registered Nurse (RN 1) and Director of Nursing (DON) acknowledged that the medical doctor should have been notified after multiple failed attempts to collect the sample. The DON stated that the failure to notify the MD and document the refusal led to a delay in care, as Resident 1 was later transferred to a hospital where a UTI was diagnosed. The facility's policy required notification of the physician after two consecutive refusals of treatment, which was not followed in this case.
Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to complete a physician-ordered urinalysis with a culture and sensitivity test for a resident, resulting in a delay of care. The resident, who had a history of dementia, urinary tract infection (UTI), and other medical conditions, was admitted to the facility with specific orders for a urinalysis and culture. Despite these orders, the urinalysis was not completed, which contributed to a delay in diagnosing and treating the resident's UTI. The resident's care plan included monitoring for signs and symptoms of a UTI, but the facility did not follow through with the necessary testing. The resident exhibited changes in behavior and confusion, which are potential indicators of a UTI, yet the urinalysis was not performed. Interviews with the nursing staff revealed uncertainty about the protocol for handling a resident's refusal to provide a urine sample, and there was a lack of documentation regarding attempts to collect the sample or notify the physician of the refusal. The Director of Nursing acknowledged that the physician should have been notified of the resident's refusal and that the lack of documentation and follow-up contributed to the delay in care. The facility's policy required staff to process test requisitions and arrange for tests, but this was not adhered to in this case. The resident was eventually transferred to a hospital, where the UTI was diagnosed, indicating a delay in care that could have been avoided if the facility had completed the ordered tests.
Failure to Prepare Puree Diet Consistently
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for a resident on a puree diet. The resident was served puree bread that was too sticky and did not pass the spoon tilt test, which is used to determine the appropriate consistency of puree foods. This failure was observed during a lunch service, where the puree bread did not fall off the spoon as required by the International Dysphagia Diet Initiative (IDDSI) Level Four standards. The deficiency was identified when a staff member, responsible for preparing the puree bread, did not follow the recipe and failed to measure the thickener accurately. Instead, the staff member relied on visual estimation and past experience to determine the consistency of the puree bread. This resulted in a product that was not in compliance with the required texture and consistency standards, potentially putting the resident at risk. Interviews with various staff members, including the Dietary Supervisor and Speech Therapist, confirmed that the puree bread did not meet the necessary standards and could pose a choking hazard. The facility's policy and procedure documents, as well as the diet manual, clearly outlined the requirements for puree diets, including the need for food to pass the spoon tilt test and not be sticky. However, these guidelines were not adhered to in this instance, leading to the identified deficiency.
Removal Plan
- The DON and the Assistant Director of Nursing assessed Resident 1 for any signs and symptoms of aspiration and initiated a change of condition assessment and care plan.
- NAME 1 was taken off schedule and was provided an in-service by the Dietary Supervisor prior to the next meal service through a return demonstration.
- The Registered Dietitian provided an in-service to the DS, the DON, the Director of Staff Development, and the ADM on checking for IDDSI Puree Level 4 consistency using spoon tilt test and fork drip test and the IDDSI guidelines.
- The RD initiated in-service training to two cooks and six dietary aides regarding puree food preparation.
- The Speech Language Pathologist completed the screening of all residents on puree diets and made no new recommendations.
- The licensed nurses inspected the breakfast meal trays and cross checked with the physician orders.
- The RD observed the puree food preparation for breakfast, particularly the food preparation for puree pancakes.
- The RD, the DS, the Manager of the Day, and/or Registered Nurse Supervisor started conducting a puree food consistency test using the spoon tilt test methods for all meals including snacks every day for 90 days.
- The RD and the DS initiated in-service training to cooks and dietary aides regarding Daily Menu Guide, Standardized recipes, and IDDSI Puree Level 4 food preparation.
- Licensed nurses started conducting huddle rounds with the CNAs and/or RNAs every shift, daily, and as needed to observe and identify any potential concerns surrounding residents on an IDDSI Puree Level 4 diet during mealtimes and snacks for 30 days.
- During lunch mealtime, the licensed nurses started doing meal rounds where they review all meal trays prior to being served utilizing the Diet Roster report.
- The RD started conducting weekly visits and observation rounds in the Dietary Department for review and evaluation of practices, particularly food preparation of IDDSI Puree Level 4.
- The DON and/or designee will report a summary-trend analysis of the huddle rounds conducted and the tray pass findings to the Quality Assurance meeting monthly for three months for review and evaluation of effectiveness or until the deficient practice is resolved.
Failure to Ensure Resident Received Appropriate Diet
Penalty
Summary
The facility failed to ensure that a resident received and consumed food as prescribed by the physician. The resident, who had a history of chronic obstructive pulmonary disease, dysphagia, and dementia, was observed consuming a biscuit during dinner, despite being on a mechanical soft finely chopped diet. This diet was intended to accommodate the resident's swallowing difficulties. The Certified Nurse Assistant (CNA) assisting the resident broke the biscuit into small pieces and fed it to the resident, who exhibited signs of distress such as gurgling sounds and a flushed face. The CNA did not recognize these as potential signs of aspiration and continued feeding the resident. The Registered Nurse (RN) responsible for the resident's care did not review the patient's discharge instructions from the hospital, which specified a mechanical soft finely chopped diet. Instead, the RN relied on the hospital's transfer form, which only indicated a mechanical soft diet. This oversight led to the incorrect transcription of the diet order into the facility's electronic health record, resulting in the resident receiving inappropriate food items that were not consistent with their dietary needs. Interviews with facility staff revealed a lack of training and understanding regarding the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, which is crucial for managing residents with dysphagia. The facility had not fully implemented IDDSI standards, and staff were not adequately trained to recognize and respond to signs of aspiration. This deficiency in training and communication contributed to the resident being served food that was not safe for their condition, putting them at risk of choking and aspiration.
Removal Plan
- Speech Therapist 1 completed an evaluation of Resident 32 and recommended to change the diet to puree texture, mildly thick liquid consistency due to frequently coughing up food during swallow and wet or gurgly voice quality after swallowing liquids.
- The Director of Nursing initiated a change of condition for Resident 32 and notified the resident's physician and responsible party of the resident's risk for aspiration. Resident 32 was placed on a 72-hour monitoring and a care plan was developed. Resident 32's physician ordered to continue Speech Therapist 1's recommendation.
- The Registered Dietitian provided an in-service to the Director of Nursing and the Director of Staff Development regarding food texture consistencies and the International Dysphagia Diet Initiative crosswalk reference guide.
- The Registered Dietitian presented the IDDSI crosswalk reference guide to be used as a reference for licensed nurses when transcribing a hospital diet order to facility diet order which utilizes the IDDSI framework.
- The Director of Nursing and the Director of Staff Development initiated in-service trainings to the licensed nurses, certified nursing assistants, and restorative nursing assistants on duty regarding transcription of diet orders upon admission and utilization of crosswalk reference guide for the IDDSI equivalent, aspiration precautions, signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The validation of competency was done through question and answer.
- The Director of Nursing reviewed the current residents' diet orders. No other residents on mechanical soft diet were affected by the deficient practice.
- Newly admitted and readmitted residents were reviewed by the Assistant Director of Nursing, Registered Nurse Supervisor and/or designee prior to their first meal being served daily, including weekends and holidays, for appropriateness of diet order utilizing the IDDSI crosswalk reference guide and utilizing the clinical meeting tool for 90 days or until 100% compliance is reached.
- Speech Therapist 1 conducted screening and/or evaluation of newly admitted or readmitted residents with a mechanically altered diet within 72 hours of admission and any recommendations will be reported to the physician and the licensed nurse.
- The Director of Nursing and the Director of Staff Development started providing in-services to the nursing staff regarding transcription of diet orders upon admission, IDDSI crosswalk reference guide, aspiration precautions, signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The Director of Staff Development will be responsible to track compliance and any nursing staff that were not re-educated due to vacation and or leave of absence will be provided re-education prior to the start of their next shift. Validation of compliance will be through a post-test.
- The Director of Nursing and/or designee started providing in-services to the licensed nurses regarding verification of diet orders from written hospital orders, IDDSI crosswalk reference guide, and verifying diet orders with the primary physician. Validation of compliance will be through a post-test.
- The Director of Nursing and/or designee will present a summary trend analysis of the Clinical Meeting reviews particularly with diet orders of newly admitted and/or readmitted residents and licensed nurses' meal rounds report monthly for three months to the Quality Assurance committee for further evaluations and recommendations. Monitoring systems are to remain in place for three months to be evaluated for future systems monitoring as needed by the QA Committee.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of three residents, leading to deficiencies in their care. Resident 45, who has multiple sclerosis, type 2 diabetes mellitus, and chronic kidney disease, was transported from the shower to his room with inadequate covering, leaving his sides exposed. This was observed by the Assistant Director of Nursing, who noted that the resident was only covered with a single sheet and a towel over his head, which was insufficient for his size. The Certified Nursing Assistant responsible admitted to using only one sheet, acknowledging that it did not fully cover the resident, thus compromising his privacy. Resident 53, diagnosed with diabetes mellitus, end-stage renal disease, glaucoma, and dementia, was observed sitting in bed with her hospital gown unsecured, exposing her bare back and side to the hallway. The Infection Preventionist entered the room without noticing the exposure, failing to ensure the resident's privacy. It was only after being informed that the Infection Preventionist adjusted the gown and closed the privacy curtain. The Director of Nursing later confirmed that staff should have immediately addressed such dignity issues to prevent potential psychosocial impacts on the resident. Resident 4, who has cerebral infarction, dysphagia, and generalized muscle weakness, was found sitting in a wheelchair wearing only a gown and a blue shirt, rather than her own clothing. The Restorative Nursing Assistant and Certified Nursing Assistant involved in her care acknowledged that the resident should have been dressed in her own clothes to maintain her dignity and self-esteem. The facility's policy on dignity, which emphasizes the importance of residents wearing their preferred clothing, was not followed in this instance.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. Resident 242 was admitted with a Stage 4 pressure injury on the right buttock but was not provided with a low air loss mattress (LALM) as required. Additionally, there was no accurate assessment of the pressure injury, and a baseline care plan addressing the injury was not developed or implemented. The lack of a thorough skin assessment upon admission and the absence of a physician's order for the LALM contributed to the deficiency. Resident 24, who had multiple Stage 4 pressure ulcers, was found with their LALM turned off due to a lack of available electrical outlets. This oversight was confirmed by RN 3, who acknowledged the risk of worsening the resident's wounds and causing pain. The facility's policy required the use of LALM for residents with skin breakdown or at risk for pressure ulcers, but this was not adhered to, leading to potential harm for Resident 24. Similarly, Resident 26, who was at risk for pressure ulcers, also had their LALM turned off due to unavailable outlets. This was confirmed by RN 3, who noted the potential for developing pressure injuries and causing discomfort. The facility's failure to ensure the LALM was operational for both Residents 24 and 26, despite having orders for such support surfaces, demonstrated a lack of adherence to their own policies and procedures, placing the residents at risk for further skin breakdown.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and documentation for a resident receiving hemodialysis, identified as Resident 76. The resident, admitted with diagnoses including end-stage renal disease and heart failure, required total dependence on staff for mobility and had a dialysis schedule of Monday, Wednesday, and Friday. Despite the facility's policy requiring assessment and documentation of the dialysis access site and vital signs after treatment, there were multiple instances where this was not done. Licensed Vocational Nurse 3 admitted to not documenting the necessary assessments on several occasions, and the Director of Nursing confirmed that the facility's protocol was not followed. The facility's policy mandates that licensed nurses complete a Dialysis Communication Record to document the resident's condition post-dialysis, including vital signs and access site condition. However, the records for Resident 76 showed missing documentation for cognitive status, access site, and return time to the facility on several dates. The Director of Nursing acknowledged the importance of this documentation to monitor potential side effects and ensure the resident's stability post-dialysis. The lack of documentation and assessment could lead to unidentified complications, as the facility's policy emphasizes the need for immediate physician notification in case of any complications.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies related to medication administration and storage. Licensed Vocational Nurses (LVNs) 2 and 5 did not administer prescribed medications to Residents 22 and 82 on multiple occasions, despite marking them as given in the Medication Administration Record (MAR). This discrepancy was discovered during an inspection of the medication carts, where the medications were found still in their blister packs. The failure to administer these medications as prescribed placed the residents at risk for complications such as high blood pressure, high blood sugar, and increased risk of blood clots. Additionally, the facility did not properly document the administration of controlled substances. LVN 1 failed to record the administration of hydrocodone acetaminophen to Resident 45 in the MAR, despite signing it out in the Antibiotic or Controlled Drug Record (ACDR). This oversight could lead to inaccurate reconciliation of controlled medications and potential drug diversion. Furthermore, LVN 1 administered metoprolol to Resident 62 without checking the heart rate as required by the physician's order, which could have resulted in adverse effects due to the medication's parameters. The facility also failed to manage medication storage properly. Expired medications were found in one of the medication carts, and the oral medication emergency kit was not replaced within the required 72-hour timeframe after being opened. These deficiencies in medication storage and management could lead to residents consuming expired medications or experiencing delays in receiving emergency medications. The facility's policies and procedures for medication administration and storage were not followed, contributing to these deficiencies.
Failure to Follow Prescribed Breakfast Menu
Penalty
Summary
The facility failed to adhere to the prescribed breakfast menu for 88 out of 92 residents on January 19, 2025. Instead of preparing the breakfast omelet as specified in the menu, the cook mistakenly prepared scrambled eggs. This deviation from the menu was confirmed through observations and interviews with the staff, including the cook and the Dietary Supervisor. The facility's policies and procedures require that menus meet the nutritional needs of residents and be followed as planned, which was not the case in this instance. The facility's menu, as reviewed, included a breakfast omelet as part of the regular diet for residents, along with other items such as apple juice, cereal, bacon, muffin, coffee, and milk. The recipe for the breakfast omelet included ingredients like margarine, flour, salt, black pepper, low-fat milk, and liquid eggs, while the scrambled egg recipe used whole milk, which contains more calories and fat. The Dietary Supervisor acknowledged that the substitution of scrambled eggs for the omelet could affect the taste and texture of the meal, highlighting the importance of following the menu to meet residents' dietary needs and preferences.
Failure to Follow Menu and Meet Nutritional Needs
Penalty
Summary
The facility failed to adhere to the established menu and did not meet the nutritional needs of 88 out of 92 residents on a specific day. The deficiency occurred when a staff member, identified as [NAME] 1, prepared scrambled eggs instead of the breakfast omelet that was listed on the menu. This deviation from the menu was confirmed through observation, interviews, and record reviews. The Dietary Supervisor acknowledged the mistake and noted that the change in food preparation could affect the taste and texture, as scrambled eggs and omelets are different foods. The facility's policies and procedures, last reviewed in July 2024, require that menus are developed to meet resident choices and nutritional needs, following national guidelines. The menu for the day in question included a breakfast omelet, which was not prepared as specified. Instead, scrambled eggs were served, which have different ingredients and nutritional content. This oversight had the potential to impact the residents' nutritional intake, as the facility's cook's spreadsheet and recipes indicated specific ingredients and portion sizes for the planned menu items.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which could potentially lead to foodborne illnesses among residents. During an initial tour of the kitchen, it was observed that resident foods were not labeled and dated, and staff foods were improperly stored in the kitchen refrigerator. Specifically, a container of hummus, a container of mashed potatoes, and three bowls of cut oranges were found without any dates. Dietary Aide 3 confirmed that the hummus and mashed potatoes belonged to staff and should not have been stored in the resident's refrigerator. The oranges were also not dated, and their condition was described as hard, leading to their disposal. Interviews with the Dietary Supervisor and the Director of Nursing revealed awareness of the issue, with the Dietary Supervisor acknowledging that the facility's policy did not specify restrictions on staff food storage in the resident refrigerator. The facility's policy and procedures on food receiving and storage, as well as infection control, were reviewed and indicated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated. The failure to adhere to these policies and procedures posed a risk of harmful bacterial growth and cross-contamination, potentially affecting 88 of the 92 medically compromised residents receiving food from the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement and maintain an effective infection control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not adhere to Enhanced Barrier Precautions (EBP) while administering medications via a gastrostomy tube to a resident. Despite the presence of an EBP sign indicating the need for gown and glove use during high-contact activities, the LVN only wore gloves and not a gown, contrary to the facility's policy. This oversight was confirmed by the Infection Preventionist and the Director of Nursing, who emphasized the importance of wearing a gown to prevent the transmission of infections, especially for residents with indwelling medical devices like a G-tube. Another deficiency was noted in the medication storage area, where a personal blanket was found on top of a discontinued medication bin. Staff members, including a Licensed Vocational Nurse and a Registered Nurse, acknowledged that personal items should not be stored in medication rooms due to the risk of cross-contamination. Despite recognizing the issue, the blanket was not immediately removed, indicating a lapse in maintaining a sanitary environment. Additionally, a medication cart was found to contain personal belongings such as an electric razor, watch, and car keys, which should not have been stored there, as confirmed by the Director of Nursing. Further deficiencies were observed in the handling of respiratory equipment. Several residents' nasal cannula and nebulizer tubing were either not labeled with the date of last change or were found touching the floor, which could lead to contamination. The Infection Preventionist and other staff members confirmed that these practices were against the facility's policies, which require tubing to be changed weekly and kept off the floor to prevent infection. These lapses in infection control practices highlight the facility's failure to adhere to its own policies and procedures, potentially putting residents at risk of infection.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the use of unnecessary psychotropic medications by not obtaining informed consent for the use of lorazepam. The resident, who was admitted with diagnoses including depressive disorder, anxiety disorder, and genetic torsion dystonia, had the capacity to understand and make decisions. Despite this, there was no documented evidence of informed consent for the administration of lorazepam, a psychotropic medication prescribed for anxiety. The facility's policy requires informed consent for all medications affecting behavior, but this was not followed. Interviews with the Licensed Vocational Nurse and the Director of Nursing revealed that the facility did not adhere to its policy and procedure regarding psychotropic medications. The resident confirmed that no one had explained or discussed the possible side effects of lorazepam with her. The facility's policy mandates that residents be involved in the medication management process, which includes understanding the indications for use, dosage, duration, and potential adverse effects. The lack of informed consent meant the resident was not fully informed about the medication's risks and benefits, as required by the facility's policy.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical component for summoning assistance. The resident, who was admitted with conditions including dementia, difficulty walking, muscle weakness, and a history of falls, was observed on multiple occasions without the call light within reach. This oversight was noted during observations on two separate days, where the call light was either placed on a nightstand or clipped to a bed sheet, both out of the resident's reach. Certified Nursing Assistant 3 acknowledged the oversight, stating that the resident was confused and visually impaired, and therefore needed the call light within reach to call for assistance. The CNA admitted that the call light was not placed correctly and expressed regret for the oversight. Another staff member, CNA 9, also admitted to returning the resident to their room without ensuring the call light was accessible, acknowledging the importance of the call light for resident safety and communication. The Director of Nursing confirmed that the facility's policy required call lights to be within reach of residents at all times, emphasizing the importance of this for resident safety and emotional well-being. The failure to adhere to this policy was acknowledged as a deficiency, with the potential to delay care and services, and possibly lead to resident frustration or injury. The facility's policy on call lights and fall risk management was reviewed, highlighting the need for staff to anticipate resident needs and ensure a safe environment.
Failure to Develop Care Plan for Resident's Screaming Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 247, who was admitted with a history of falling, dementia, and generalized muscle weakness. Despite the resident's documented moderately impaired cognition and need for assistance with activities of daily living, there was no care plan addressing the resident's screaming behavior. This behavior was observed on multiple occasions, where the resident screamed for assistance due to pain but declined pain medication when offered, stating she was not in pain. Interviews with facility staff, including a Licensed Vocational Nurse and Registered Nurses, confirmed the absence of a care plan for the resident's screaming behavior. The Director of Nursing acknowledged that licensed nurses are responsible for developing care plans when there are issues that need to be addressed. The facility's policy on care plans emphasizes the need for comprehensive, person-centered plans with measurable objectives and interventions addressing the underlying sources of problems, which was not adhered to in this case.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary care and services to maintain good nutrition for a resident, identified as Resident 242, who required assistance with activities of daily living, specifically eating. Resident 242 was admitted with diagnoses including cerebral infarction, dementia, and generalized weakness, and was documented as needing one-person physical assistance with eating. During an observation, it was noted that Resident 242's breakfast tray remained untouched, and the resident was unable to follow instructions or assist herself with eating. Certified Nursing Assistant 9 (CNA 9) acknowledged that the resident's breakfast tray was untouched and admitted to not providing the necessary assistance with eating. CNA 9 stated that if a resident does not want to eat, alternatives should be offered, and assistance should be provided. Both the Registered Nurse and the Director of Nursing confirmed that staff are required to assist residents who are unable to eat by themselves, and failure to do so could lead to nutritional issues. The facility's policy indicated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, which was not adhered to in this case.
Failure to Follow Up on Lab Draw for Seizure Medication
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not following up on a lab draw for phenobarbital, a medication used to control seizures. The resident, who was originally admitted in 2016 and readmitted later with diagnoses including epilepsy, anxiety disorder, and COPD, had a physician's order for phenobarbital to be administered twice daily and for lab draws to monitor the medication levels. However, the facility did not have any notes or lab results for the phenobarbital draw ordered on a specific date, which was crucial for maintaining the resident's lab values within the therapeutic range as per the care plan. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for lab draws was not followed. The ADON acknowledged the potential harm to the resident if phenobarbital levels were not monitored, which could lead to ineffective seizure control or toxicity. The DON explained the procedure for lab draws, which involves the licensed nurse ensuring requisitions are checked and following up with the physician if a draw is missed. Despite these protocols, the facility's failure to ensure the lab draw was completed and documented resulted in a deficiency in providing resident-centered care.
Deficiencies in Resident Safety and Medication Management
Penalty
Summary
The facility failed to ensure a safe environment for Resident 38 by allowing an overbed table to be placed on top of the resident's floor mat. This practice was observed during a room inspection, where the table was found to be unstable and posed a risk of falling on the resident. Both a CNA and an RN confirmed the improper placement of the table and acknowledged the potential hazard it created. The resident, who had a history of falls and severely impaired cognition, required a safe environment as part of their care plan, which was not adhered to in this instance. In another incident, the facility failed to prevent medication hazards for Resident 7 by leaving trazodone pills unattended at the resident's bedside. The resident, who was not deemed safe to self-administer medication, had the pills left by an LVN who trusted the resident to take them later. This action was against the facility's policy, which requires supervision during medication administration to prevent potential overdose or ingestion by other residents. The LVN admitted to not following proper procedures, which could have led to serious consequences. Both deficiencies highlight a lack of adherence to the facility's policies and procedures regarding resident safety and medication administration. The facility's policies clearly state the need for individualized safety measures and proper supervision, which were not implemented in these cases. The DON confirmed that the facility's policies were not followed, emphasizing the importance of maintaining a safe environment and proper medication management to prevent accidents and ensure resident well-being.
Failure to Label Open Date on Medication
Penalty
Summary
The facility failed to properly label the open date of Senna, a natural laxative, on one of its medication carts, specifically Medication Cart 2. During an observation and interview, it was noted that the Senna container, which had an expiration date of September 2027, did not have an open date labeled. Licensed Vocational Nurse 7 admitted to opening the Senna container on the day of the observation but did not label it with an open date. This oversight was acknowledged by the LVN, who stated that medications must have an open date to ensure proper tracking and usage. The Director of Nursing confirmed that over-the-counter medications should have an open date and explained that medications should be discarded three months after opening, regardless of the expiration date. A review of the facility's policies and procedures indicated that medications should be stored safely and properly, following the manufacturer's recommendations. The policy also stated that medications without secure closures or proper labeling should be immediately removed from stock. However, the Senna container on Medication Cart 2 did not comply with these guidelines, leading to the deficiency.
Failure to Lock Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required by professional principles. On the morning of November 27, 2024, it was observed that Medication Cart B and the Middle Cart were not locked at 6:17 a.m., and Treatment Cart B was not locked at 6:30 a.m. These observations were made at Nurse's Station 1, where a Licensed Vocational Nurse (LVN 2) and a Registered Nurse (RN 3) confirmed that the carts should have been locked to prevent unauthorized access by residents. The Director of Nursing (DON) also confirmed during an interview that medication carts must be locked at all times to ensure residents' safety, as unauthorized access could lead to adverse effects, overdoses, or allergic reactions. The facility's policy, last revised in February 2023, mandates that compartments containing drugs and biologicals must be locked when not in use, and transport trays or carts should not be left unattended if open or accessible to others.
Failure to Administer Insulin Per Physician's Order
Penalty
Summary
The facility failed to administer insulin according to the physician's order for a resident diagnosed with diabetes mellitus, among other conditions. The resident was admitted with diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, and diabetes mellitus. The care plan for the resident included an intervention for diabetes medication as ordered by the physician, specifically insulin regular human injection solution per sliding scale. The physician's order detailed specific insulin dosages based on blood sugar levels, with instructions to rotate injection sites and notify the physician if blood sugar levels were less than 70 or more than 400. On two occasions, the resident's blood sugar levels were recorded as 188 and 168, respectively, but the regular insulin was not administered as per the sliding scale order. The registered nurse confirmed that the insulin should have been given on both occasions, as the blood sugar levels fell within the parameters requiring insulin administration. The assistant director of nursing also acknowledged that the licensed vocational nurses involved should have followed the physician's order, as per the facility's policy and procedure for administering medications.
Failure to Maintain Homelike Environment Due to Delayed Removal of Deceased Resident
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents when a deceased resident was left in their shared room for approximately 13 hours. The deceased resident passed away at 6 p.m., and his body remained in the room until 7 a.m. the following day. This situation involved Resident 2, who had a history of psychosis, dysphagia, anxiety disorder, and schizophrenia, and Resident 3, who had major depressive disorder, anxiety disorder, and insomnia. Both residents were exposed to the deceased body during this time. Interviews with staff revealed that the deceased resident's body was not moved promptly, despite awareness of the death by multiple staff members, including a Licensed Vocational Nurse, Registered Nurses, and the Assistant Director of Nursing. The staff acknowledged that the presence of the deceased body could cause fear and affect the mental health of the roommates, Resident 2 and Resident 3. The Director of Nursing also recognized that the situation could have psychosocial effects on the roommates and that the body should have been moved sooner. The facility's policy on providing a homelike environment was not adhered to, as the presence of a deceased body in the room compromised the residents' sense of safety and comfort. The report highlights the failure to maintain a homelike environment, as the deceased resident's body was left in the room with the other residents, causing distress and fear among them.
Failure to Provide Social Services After Roommate's Death
Penalty
Summary
The facility failed to provide medically-related social services to maintain the highest practicable psychosocial well-being for two residents after their roommate passed away. Resident 2 and Resident 3 were not given follow-up visits by the social services department after the death of their roommate, Resident 1. This oversight had the potential to increase stress and anxiety for Residents 2 and 3. Resident 2 was admitted with diagnoses including unspecified psychosis, dysphagia, anxiety disorder, and schizophrenia. The care plan indicated the use of psychotropic medication and extensive assistance with daily activities. Resident 3 was admitted with major depressive disorder, anxiety disorder, and insomnia, and was on antidepressant medication. The Minimum Data Set (MDS) for Resident 3 indicated cognitive intactness and required supervision for some activities. Interviews with staff revealed that Resident 1's body remained in the shared room with Residents 2 and 3 for approximately 13 hours after death. Staff members, including LVNs, RNs, and the DON, acknowledged that the presence of a deceased body could cause fear and affect the mental health of the roommates. The facility's policies on providing a homelike environment and behavioral health services were not adhered to, as the residents were not evaluated for psychological issues following the incident.
Delayed Physician Notification for Elevated Pulse Rate
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a significant change in a resident's condition. On the morning of May 30, 2024, a resident exhibited an elevated pulse rate of 126 beats per minute at 9:10 a.m., but the physician was not informed until 12:40 p.m. This delay in communication resulted in a postponement of obtaining necessary medical instructions for the resident's care. The resident, who was admitted on May 3, 2024, had a medical history that included pneumonia, chronic obstructive pulmonary disease (COPD), and dementia, and was noted to have severely impaired cognitive skills and was dependent on staff for daily activities. The Director of Nursing (DON) acknowledged during an interview that the physician should have been notified immediately at 9:10 a.m. due to the elevated pulse rate. The facility's policy, reviewed in January 2024, mandates prompt notification of the physician for any significant change in a resident's condition, including changes in vital signs. The policy specifies that a significant change is one that will not resolve without intervention. The failure to adhere to this policy led to a delay in the resident receiving appropriate medical evaluation and intervention.
Failure to Develop Comprehensive Care Plan for Tachycardia
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with diagnoses including pneumonia, chronic obstructive pulmonary disease (COPD), and unspecified dementia. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities. On a specific date, the resident exhibited tachycardia with pulse rates recorded at 126 and 122. Despite the physician being notified and ordering an immediate electrocardiogram (ECG), the facility did not create a care plan to address the resident's elevated pulse rate. During a review of the resident's care plans, the Director of Nursing (DON) confirmed that no care plan had been developed to manage the resident's tachycardia. The facility's policy on comprehensive person-centered care plans requires the development of measurable objectives and timetables to meet residents' needs, which was not adhered to in this case. This oversight had the potential to delay necessary care and services for the resident.
Failure to Adhere to Physician's Order for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services by not adhering to the physician's order for administering metoprolol tartrate to a resident. The resident, who was admitted with diagnoses including pneumonia, COPD, and dementia, was prescribed metoprolol tartrate to be administered via gastrostomy tube twice daily for hypertension, with instructions to hold the medication if the systolic blood pressure was below 120 or the heart rate was below 60. However, the medication was administered on three occasions despite the resident's systolic blood pressure being below the threshold specified in the physician's order. The Director of Nursing confirmed that the Licensed Vocational Nurses involved should have withheld the medication as per the physician's instructions. The facility's policy on administering medications, which requires checking vital signs before administration, was not followed. This oversight had the potential to result in medication errors and delay in necessary care, potentially leading to ineffectively managed hypertension for the resident.
Failure to Ensure Safe Discharge to Appropriate Facility
Penalty
Summary
The facility failed to ensure a safe discharge for a resident by not adhering to the physician's order to discharge the resident to a board and care facility. Instead, the resident was discharged to an independent living facility, which was unlicensed and did not provide the necessary level of care. The resident had been admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and adult failure to thrive, and was dependent on staff for various daily activities, indicating a need for a higher level of care. The discharge process was marred by several communication and documentation failures. The Placement Coordinator was not informed of the physician's order to discharge the resident to a board and care facility, and the contact number for the board and care facility was not documented in the resident's medical record. Additionally, the Social Service Director was not aware that the resident had chosen an independent living facility over the board and care options presented, leading to a discharge that did not align with the physician's order. Interviews with facility staff revealed a lack of verification and follow-up regarding the resident's chosen discharge location. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of ensuring residents are discharged to the correct level of care as per physician orders. The facility's policies on documentation and discharge planning were not followed, contributing to the unsafe discharge of the resident.
Failure to Establish Protocol for Mortuary Pick-Up
Penalty
Summary
The facility failed to ensure an engaged governing body was responsible for establishing and implementing policies regarding the management of the facility, resulting in a deficiency. This was evidenced by the incident involving a resident who expired in the facility and whose body remained uncollected for over 12 hours. The resident, who was admitted with severe cognitive impairments and was dependent on staff for all activities of daily living, passed away at 6 p.m. Despite multiple attempts to contact mortuary services, the body was not picked up until the following day after emergency services were called. Interviews with staff revealed a lack of clear procedures and communication regarding the handling of the deceased resident's body. The Director of Nursing and other staff members acknowledged the absence of a policy for mortuary pick-up and the lack of a mortuary contract. The Administrator admitted to being informed of the situation only the next morning and stated that the nurses could have contacted him for assistance. The facility's policy indicated that the governing board is responsible for the management and operation of the facility, yet there was no established protocol for this situation, leading to the deficiency.
Failure to Document Contact Information for Resident Discharge
Penalty
Summary
The facility failed to ensure accurate documentation for a resident by not including the contact number of the independent living facility in the resident's medical record. The resident, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and adult failure to thrive, was discharged to an independent living facility. Despite having the capacity to understand and make decisions, the resident's cognitive skills for daily decisions were severely impaired, and they required assistance with various activities of daily living. The discharge order indicated a transfer to a Board and Care facility, but the discharge summary left the contact number blank. Interviews revealed that the resident was picked up by Board and Care transportation, but later returned to the hospital. The Social Service Director admitted to forgetting to document the contact number, which is crucial for follow-up calls. The Assistant Director of Nursing confirmed there was no documented evidence that the resident was informed about the discharge to Board and Care as per the physician's order. The facility's policies emphasize the importance of complete and accurate documentation, which was not adhered to in this case.
Failure to Assess Residents for Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess three residents for the risk of entrapment before installing bed rails. Resident 1, admitted with diagnoses including spinal fusion, muscle weakness, and difficulty walking, was found with quarter-length bed rails without a prior assessment. Both the resident and the Certified Nursing Assistant (CNA) confirmed that no side rail use assessment was performed. The Director of Nursing (DON) acknowledged the oversight and noted an overdue alert for the assessment in the electronic medical record. Resident 2, admitted with generalized muscle weakness and a history of falling, also had quarter-length bed rails installed without an assessment. The resident confirmed the lack of assessment, and the Registered Nurse (RN) and DON both verified that no assessment was documented. The DON reiterated the importance of assessing residents before implementing bed rail use. Resident 3, admitted with coordination issues, difficulty walking, and a history of falling, was similarly found with quarter-length bed rails without an assessment. The resident and RN confirmed the absence of an assessment, and the DON noted that the rehabilitation department should have conducted one. The facility's policy mandates a comprehensive assessment for bed rail use, including evaluating medical conditions, mobility, and risk of entrapment, which was not followed in these cases.
Inaccurate Fall Risk Assessment
Penalty
Summary
The facility failed to provide an environment free from accidents when a resident was not accurately evaluated for fall risk. The resident, admitted with diagnoses including spine fusion, generalized muscle weakness, and difficulty in walking, was assessed on admission and scored a seven on the Fall Risk Assessment. According to the facility's policy, any score greater than zero should indicate a fall risk. However, the assessment incorrectly marked the resident as not at risk for falls. This error was confirmed during interviews with both a Registered Nurse and the Director of Nursing, who acknowledged that the resident should have been identified as at risk for falls. The resident's Minimum Data Set indicated they required varying levels of assistance with daily activities and had experienced a fall with injury since admission. Despite these indicators, the fall risk assessment did not reflect the resident's true risk, potentially leading to inadequate care planning and fall prevention measures. The facility's policy emphasized the importance of accurate fall risk assessments to develop effective care plans, but this was not adhered to in this case, resulting in a significant oversight in the resident's care management.
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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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