Valley Village Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 13000 Victory Blvd, North Hollywood, California 91606
- CMS Provider Number
- 555012
- Inspections on file
- 52
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Valley Village Care Center during CMS and state inspections, most recent first.
A resident with impaired cognition and multiple health issues was not promptly reported missing after leaving the facility with a family member. An LPN spent 30 minutes searching alone before notifying the RN, delaying the code pink response and resulting in the resident missing a prescribed insulin dose for elevated blood sugar. Facility policy required immediate action, which was not followed.
A facility failed to rotate insulin injection sites for a resident with diabetes, contrary to guidelines, risking adverse effects. Additionally, another resident on anticoagulant therapy lacked necessary monitoring for bleeding, as no physician's order was in place. These deficiencies were confirmed by staff and identified through interviews and record reviews.
The facility failed to maintain a safe environment, leading to potential accident hazards for several residents. A resident's path to the bathroom was obstructed, medications were left unattended, and fall risk assessments were inaccurately documented. Additionally, two residents had furniture placed on their floor mats, compromising safety. Staff interviews confirmed these deficiencies.
A LTC facility failed to provide adequate pharmaceutical services for five residents, leading to several deficiencies. Medications for a resident were not labeled with the complete date of opening, and another resident received pain medication against physician orders. Additionally, a resident's medication count was inaccurately documented, and potassium was administered with insufficient water. Lastly, a resident on heparin was not monitored for bleeding due to a lack of physician orders. These actions were against the facility's policies and procedures.
Two residents in a facility experienced significant medication errors. One resident with diabetes received insulin injections without proper site rotation, contrary to professional standards and facility policy. Another resident was given heparin without the route of administration being specified in the physician's order, leading to 102 instances of administration without clarification. Staff acknowledged these errors, which were identified through interviews and record reviews.
The facility failed to maintain safe food storage and preparation practices, with unmonitored storage room temperatures and expired or unlabeled food items found in the kitchen. Staff interviews confirmed the importance of proper labeling and temperature monitoring to prevent foodborne illnesses, as outlined in the facility's policies.
The facility failed to maintain infection control by not cleaning Prostat bottles on medication carts and lacking knowledge of legionella indicators. LVNs admitted to not cleaning sticky Prostat bottles, violating policy. The Maintenance Director and Infection Preventionist were unaware of biofilm, crucial for legionella prevention, compromising the water management program.
A resident with severe cognitive impairment was exposed during care when a CNA failed to fully close the privacy curtain, breaching the facility's dignity and privacy standards. Interviews confirmed the importance of maintaining privacy to protect residents' self-esteem and self-worth.
The facility failed to obtain written informed consent for two residents before administering antidepressants, violating their rights to make informed decisions. One resident, with severely impaired cognitive skills, did not have their representative's consent documented for bupropion use. Another resident, with moderate cognitive impairment but decision-making capacity, did not have their consent documented for venlafaxine use. The facility's policy requires written consent before administering psychotherapeutic medications, which was not followed in these cases.
The facility failed to ensure call lights were within reach for two residents, both at high risk for falls and requiring substantial assistance. Despite care plans and physician orders indicating the need for accessible call lights, staff did not comply, leaving one resident's call light on the floor and another's out of reach. Observations confirmed these deficiencies, which could delay care and services.
The facility failed to inform two residents about their right to formulate an advance directive, violating their rights. One resident, with conditions like cardiomyopathy, was not offered information about advance directives upon admission. Another resident, unable to make medical decisions, had no documentation of advance directive discussions with their representative. The facility's policy requires providing such information and documenting decisions, which was not followed.
A facility failed to notify a resident's representative of a low iron level, violating the policy for changes in condition. The resident, with multiple diagnoses, had a lab result indicating low iron, but no SBAR was completed, and the family was not informed. The DON confirmed the need for an SBAR and care plan, which were not done.
A facility failed to maintain the confidentiality of a resident's medical records when an LVN left an EHR open and unattended. The incident involved a resident with a history of TIA, hypertension, and hyperlipidemia. The LVN acknowledged the oversight, and the DON confirmed the requirement to minimize screens to protect resident information.
A facility failed to provide a safe and homelike environment for a resident by not replacing a torn floor mat, which was part of the resident's fall prevention plan. The resident, who had severe cognitive impairment and required total assistance with daily activities, was affected by this deficiency. The facility's policy emphasized the importance of maintaining a clean and safe environment, and staff were responsible for reporting any equipment in disrepair.
A resident's bed was positioned against the wall, restricting movement without proper documentation or consent. Despite the resident's ability to make decisions, there was no restraint assessment, informed consent, or care plan. Staff were unaware of the rationale, and the facility's policy on restraint use was not followed, posing potential risks to the resident.
The facility failed to timely develop comprehensive care plans for two residents. One resident, readmitted with a heparin order, had a care plan initiated nearly a month late, while another resident with low iron levels had no care plan for monitoring anemia or addressing iron supplementation risks. These deficiencies could delay necessary care and treatments.
A facility failed to update a resident's care plan after a physician increased the dosage of bupropion and changed insulin orders. The care plan, last updated months prior, did not reflect these changes, potentially delaying necessary care. Interviews with staff confirmed the oversight, highlighting the importance of updating care plans to guide medication administration and ensure all staff are aware of current care plans.
A resident with hemiplegia and malnutrition was not consistently provided with meal assistance as ordered by the physician. Despite requiring significant help and cueing to eat, the resident's need for assistance was not reflected in staff assignments, leading to minimal food intake. Observations and staff interviews confirmed the lack of adherence to facility policies on meal assistance.
A resident with multiple diagnoses, including hemiplegia and epilepsy, had a low iron level detected in lab results. Despite notifying the NP and initiating treatment with ferrous sulfate, the facility failed to create an SBAR to document and monitor the resident's condition. Interviews with staff confirmed the necessity of an SBAR for such changes, as per facility policy.
A resident with a history of hemiplegia and malnutrition was not provided with necessary meal assistance, leading to inadequate food intake. The facility failed to notify the resident's MD when the resident consumed less than 50% of meals on multiple occasions, contrary to the care plan. Staff interviews revealed inconsistencies in communication and documentation, posing a risk of malnutrition and delayed care.
A facility failed to conduct necessary behavioral IDT meetings for a resident on Seroquel and escitalopram, despite multiple behavioral episodes. The resident, with diagnoses including dementia and depression, had care plans requiring medication discussions, but no IDT meetings with the psychiatrist were documented. Facility staff confirmed the lack of documentation and the importance of these meetings for medication adjustments.
A facility failed to act on a pharmacist's recommendation for a TSH blood draw for a resident on amiodarone, and did not identify irregularities in another resident's anticoagulant regimen. The first resident did not have a TSH test ordered or conducted, and the second resident received heparin without clarifying discrepancies in the physician's order and medication label. The facility's medication regimen review policy was not followed, leading to potential risks for the residents.
A facility failed to obtain informed consent for a resident when increasing the dosage of bupropion, a psychotropic medication. The resident, with impaired cognitive skills and lacking decision-making capacity, had their medication increased without the necessary consent, contrary to facility policy. Interviews with facility staff confirmed the oversight, emphasizing the importance of adhering to protocols for resident rights and medication administration.
Two medication errors resulted in a 7.69% error rate at an LTC facility. An LVN gave a resident potassium chloride with insufficient water, against physician orders. Another LVN administered heparin without clarifying the order, which lacked a specified route. Both errors were confirmed through staff interviews and policy reviews.
A facility failed to follow the prescribed menu and meet the nutritional needs of a resident at nutritional risk due to adult failure to thrive. The resident's care plan required adherence to a diet and consideration of food preferences. A delivery issue led to a substitution of corn for green beans, which the resident disliked and refused to eat. The Dietary Supervisor acknowledged the error, and the Registered Dietitian confirmed the substitution but was unaware of the resident's refusal, potentially affecting the resident's intake.
A resident's medical records contained inaccurate documentation of blood pressure, leading to potential confusion in care. The MAR showed a blood pressure of 18/62 instead of the correct 118/62, affecting medication administration. Interviews with staff highlighted the importance of accurate documentation, as per facility policy.
A facility failed to involve a resident or their representative in the initial IDT meeting for hospice care planning, despite the resident's severe cognitive impairment and need for substantial assistance. This oversight, confirmed by staff interviews, contradicted the facility's policy and had the potential to delay necessary hospice services.
A resident receiving vancomycin for pneumonia was not monitored for side effects as required by the facility's policy. Despite the medication being administered, there was no documentation of monitoring in the MAR, Progress Notes, or Daily Skilled Medicare Charting. Interviews with staff confirmed the deficiency in following the facility's antibiotic stewardship and infection surveillance policies.
A resident's bed controller cable was found with a chipped part and exposed screws, posing a risk of injury. The facility's maintenance department was responsible for equipment upkeep, but staff were expected to report issues. Interviews revealed uncertainty about maintenance schedules and emphasized the need for immediate notification of equipment disrepair. Facility policies stressed a safe and homelike environment, yet the damaged equipment was not promptly addressed.
A resident with severe cognitive impairment and dependency on staff was found with bruising and swelling on their hand. Despite concerns from a family member about potential mishandling by staff, the facility failed to report the allegation of abuse to the SSA and Ombudsman within the required two-hour timeframe. The incident highlighted a breakdown in communication and adherence to the facility's abuse reporting policy.
A resident with Alzheimer's and other conditions was given hydrocodone-acetaminophen for a pain level of seven, against the physician's order to administer ibuprofen for moderate pain. The DON confirmed the nurse's error, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to ensure call lights were within reach for two residents at high risk for falls. One resident's call light was found hanging on a TV rack, while another's was wedged between the mattress and bedside rails, making them inaccessible. The ADON and DON confirmed these deficiencies, which could delay care and assistance.
A resident with a high fall risk was not provided with fall mats on both sides of their bed, despite being assessed as high risk for falls. The facility's huddle reports were inconsistent, failing to consistently communicate the resident's fall risk to staff. Observations and staff interviews confirmed the absence of necessary fall prevention measures, posing a risk of injury.
A facility failed to provide a resident's requested medical records in a timely manner, violating its policy. The resident, with severe cognitive impairment and heart failure, had requested records that were not fulfilled as per the facility's guidelines. Both the Medical Records Director and the DON confirmed the delay and acknowledged the potential policy violation.
A resident with end-stage renal disease and mobility issues experienced a breach of dignity when a transportation attendant yelled 'You shut up!' at them while returning from dialysis. The incident, witnessed by an LVN, was deemed inappropriate by nursing staff, who emphasized the need for respectful communication. The facility's policy on resident rights was not followed, potentially causing emotional distress to the resident.
A facility failed to implement a person-centered care plan for a resident who was noncompliant with a physician-ordered diet. Despite having intact cognitive skills and requiring moderate assistance for daily activities, the resident preferred to order food from outside the facility, which was not addressed in their care plan. Staff interviews revealed a lack of awareness and action regarding the resident's dietary noncompliance, contrary to facility policies requiring staff to approve outside food to ensure diet compliance.
A resident with medical conditions requiring moderate assistance was allowed to leave the facility unsupervised multiple times without a physician's order. The facility's policy required such an order, but it was not obtained, and staff failed to document the resident's departure and return times, placing the resident at risk for accidents.
A transporter failed to wear a facemask while picking up a resident for an appointment, despite the facility's policy requiring masks due to a recent COVID-19 case among staff. The resident had severe cognitive impairments and was at risk due to the transporter's non-compliance with infection control measures.
The facility failed to provide necessary respiratory care for two residents by not ensuring their oxygen tubings were dated when changed and free from kinks. One resident had a kinked oxygen tubing and undated supplies, while another resident had undated oxygen tubing. The facility's policy required oxygen supplies to be replaced every 7 days, but this was not followed.
Failure to Immediately Initiate Missing Resident Protocol
Penalty
Summary
The facility failed to immediately initiate its missing resident protocol, known as 'code pink,' when a resident with multiple complex medical conditions was discovered missing. The resident, who had moderately impaired cognition and required assistance with daily activities, was last seen in their room with a family member. After a blood sugar check revealed a high reading, a nurse received an order to administer insulin. When the nurse returned to the resident's room to give the medication, the resident and the family member were gone. Instead of immediately reporting the resident as missing and calling code pink, the nurse spent approximately 30 minutes searching the facility alone before notifying the charge nurse. Only then was code pink announced and a broader search initiated, including contacting the administrator, DON, and police. Security footage later showed the resident and family member leaving the facility during this time frame. The delay in following the facility's policy for missing residents resulted in the resident missing a prescribed dose of insulin for elevated blood sugar. Interviews with staff confirmed that the code pink should have been called as soon as the resident was found missing, and that the delay was not in accordance with facility policy. The facility's own policies require immediate action and notification when a resident is suspected missing.
Deficiencies in Insulin Administration and Anticoagulant Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of care in the administration of insulin for a resident with type 2 diabetes mellitus. The resident, who had severely impaired cognition and required total assistance with activities of daily living, was not receiving insulin injections with proper site rotation. The insulin was repeatedly administered in the same areas of the abdomen, contrary to the manufacturer's guidelines and facility policy, which require rotation to prevent adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis. Both the Licensed Vocational Nurse and the Assistant Director of Nursing acknowledged that the insulin administration sites were not rotated as required. Additionally, the facility failed to implement appropriate monitoring for a resident receiving anticoagulant therapy with heparin. The resident, who also had severely impaired cognition and required total assistance with daily activities, did not have a physician's order for monitoring signs and symptoms of bleeding, which is crucial for residents on anticoagulant therapy. The Registered Nurse and the Assistant Director of Nursing confirmed the absence of such an order and acknowledged that monitoring should have been in place to prevent complications related to anticoagulant use. The facility's policies and procedures for insulin administration and anticoagulant therapy were not followed, leading to deficiencies in care. The lack of adherence to these protocols posed potential risks to the residents, as the insulin administration sites were not rotated, and there was no monitoring for bleeding in a resident on anticoagulant therapy. These failures were identified through interviews and record reviews conducted by the surveyors.
Facility Fails to Prevent Accident Hazards and Ensure Proper Supervision
Penalty
Summary
The facility failed to ensure a safe environment for several residents, leading to potential accident hazards. Resident 23's pathway to the bathroom was obstructed by a roommate's wheelchair, which could have caused a fall. Despite being identified as at risk for falls, the resident's care plan was not adequately followed, as staff did not ensure an unobstructed path to the bathroom. Interviews with staff confirmed the obstruction and the potential risk it posed to the resident. Resident 92's medications, including acetaminophen and enoxaparin, were left unattended on top of a medication cart by LVN 4. This practice posed a risk of the medications being taken by another resident or person. The facility's policy requires that medication carts be kept closed and locked when out of sight, which was not adhered to in this instance. Interviews with LVN 4 and the DON confirmed the lapse in protocol and the potential risk involved. The facility also failed to accurately document Resident 95's fall risk assessment after a fall, which could have led to inappropriate interventions. The resident's fall risk score was inaccurately lowered, despite the resident's continued risk factors. Additionally, Residents 297 and 32 had floor mats with furniture placed on top, compromising the mats' effectiveness in reducing fall impact. Staff interviews confirmed that such placement could lead to injury, as the furniture could become unstable and fall on the residents.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for five residents, leading to several deficiencies. For Resident 25, the facility did not label the Trelegy inhaler and two over-the-counter medications with the complete date, including the year, when they were opened. This oversight was observed during a medication administration review, and both the Director of Staff Development and the Director of Nursing acknowledged the importance of including the year to maintain medication efficacy and prevent errors. The facility's policy requires that all medications be properly labeled with the complete date of opening. Resident 32 received Norco, a pain medication, despite having a pain level of zero, which was against the physician's order that specified administration only for severe breakthrough pain with a level of seven to ten. This was confirmed through a review of the Medication Administration Record and interviews with the Director of Staff Development and the Director of Nursing, who emphasized the necessity of following physician orders for medication administration. Additionally, Resident 41's Medication Count Sheet for clonazepam was inaccurately documented, showing discrepancies in the number of tablets recorded versus the actual count. The Assistant Director of Nursing highlighted the importance of accurate documentation for controlled substances. For Resident 58, the facility did not adhere to the physician's order to administer potassium with a full glass of water, instead providing only two ounces. This was acknowledged by the Licensed Vocational Nurse and the Director of Nursing, who stated that a full glass is necessary to prevent stomach upset. Lastly, Resident 2 was not monitored for signs and symptoms of bleeding while on heparin, an anticoagulant, due to the absence of a physician's order for such monitoring. Both the Registered Nurse and the Assistant Director of Nursing recognized the need for monitoring orders to prevent complications. The facility's policies on medication administration and anticoagulant protocols were not followed, leading to these deficiencies.
Medication Administration Errors in Insulin and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving insulin administration and anticoagulant use. In the first case, a resident with type 2 diabetes mellitus and severely impaired cognition received insulin injections without proper rotation of the administration sites. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) confirmed that the insulin administration sites were not rotated according to standards of practice, which could lead to adverse effects such as bruising and skin conditions. The facility's policy and manufacturer's guidelines emphasized the importance of rotating injection sites to prevent such issues. In the second incident, another resident with dementia and severely impaired cognition was administered heparin, an anticoagulant, without the route of administration being specified in the physician's order. The medication label indicated a different route than what was documented in the Medication Administration Record (MAR). Despite the discrepancy, the heparin was administered 102 times without clarification from the physician. The LVN, Registered Nurse (RN), and ADON acknowledged the error, noting that the medication should have been held until the order was clarified. The facility's policy required that medications be administered according to the prescriber's orders, including the correct route. Both incidents highlight a failure to adhere to professional standards and facility policies regarding medication administration. The lack of proper site rotation for insulin injections and the administration of heparin without confirming the correct route represent significant medication errors. These deficiencies were identified through interviews and record reviews, with staff acknowledging the deviations from established protocols.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation tour, it was noted that temperatures were not checked on specific dates for the dry storage room, which is crucial for maintaining food safety. Additionally, several food items, including corn flakes, breadcrumbs, beans, and cheese, were found with expired use-by dates and were not discarded as required. Furthermore, some food items such as lentils, Lays chips, and soy sauce were not properly labeled with received, open, or use-by dates, which is necessary to ensure that food is consumed safely and not past its expiration. Interviews with staff, including a kitchen staff member and the Dietary Supervisor, confirmed that all foods should be labeled with received, open, and use-by dates to prevent the consumption of expired items. The Dietary Supervisor emphasized the importance of tracking storage room temperatures to prevent bacterial growth that could lead to foodborne illnesses. The facility's policy and procedures also require all food items to be labeled and dated, and corrective actions to be taken if storage room temperatures exceed 85°F. These deficiencies had the potential to result in harmful bacterial growth and cross-contamination, posing a risk of foodborne illness to residents.
Infection Control Deficiencies in Medication Handling and Legionella Management
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by the mishandling of Prostat bottles on medication carts. During observations, it was noted that Prostat bottles on two medication carts were sticky and had dried brown drippings on the sides. Licensed Vocational Nurses (LVNs) acknowledged the bottles were not cleaned after use, which is against the facility's policy that requires reusable equipment to be cleaned or disinfected after each use. The Director of Staff Development and the Director of Nursing confirmed that staff should clean medication bottles to prevent cross-contamination. Additionally, the facility's Maintenance Director and Infection Preventionist were unable to identify signs of legionella, a severe form of pneumonia, as outlined in the facility's Legionella Water Management Program. The Maintenance Director admitted to not knowing what biofilm was, which is crucial for identifying potential legionella growth in the water system. The Infection Preventionist, who provided training to the Maintenance Director, also did not know what biofilm was, indicating a gap in knowledge and training regarding legionella prevention. Interviews with the Director of Staff Development and the Administrator revealed that the Maintenance Director was responsible for inspecting the facility for stagnant water and selecting water samples for legionella testing. However, the lack of knowledge about biofilm and other signs of legionella growth compromised the effectiveness of the water management program. The facility's policy emphasizes the importance of preventing, detecting, and controlling water-borne contaminants, but the staff's inability to identify key indicators of legionella growth represents a significant deficiency in infection control practices.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident 13, during care. Resident 13, who has severe cognitive impairment and requires extensive assistance with activities of daily living, was exposed when Certified Nursing Assistant 5 (CNA 5) did not fully close the privacy curtain while providing care. This incident occurred during a morning observation when CNA 5 was distracted by a conversation with the Charge Nurse and neglected to ensure the curtain was fully closed, leaving the resident's buttocks exposed. Interviews with CNA 5, the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed that the facility's policy requires staff to maintain resident privacy by fully closing privacy curtains during care. Both the DSD and DON acknowledged that CNA 5's failure to close the curtain was a breach of the facility's dignity and privacy standards, which are designed to protect residents' self-esteem and self-worth. The facility's policy emphasizes the importance of promoting and protecting resident privacy during personal care and treatment procedures.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to obtain written verification of informed consent for two residents, which violated their rights to make informed decisions regarding their treatment. Resident 32, who was admitted with diagnoses including metabolic encephalopathy, generalized muscle weakness, and depression, was found to have severely impaired cognitive skills. Despite this, the facility did not document the consent of Resident 32's representative for the administration of bupropion, an antidepressant. The Assistant Director of Nursing (ADON) acknowledged that the informed consent was incomplete and emphasized the importance of having a completed consent form to ensure the resident representative's right to be informed. Similarly, Resident 76, admitted with conditions including gastroenteritis, colitis, depression, and generalized weakness, had moderately impaired cognitive skills but retained the capacity to make decisions. The facility failed to document Resident 76's consent for the administration of venlafaxine, another antidepressant. The Registered Nurse (RN) and ADON both confirmed that the informed consent was not completed before the medication was administered, which was against the facility's policy. The facility's policy on informed consent for psychotherapeutic medications requires a written consent signed by the resident or their representative, along with a healthcare professional's signature, before treatment. This policy was not adhered to in the cases of Residents 32 and 76, as their informed consents were incomplete, and medications were administered without proper documentation of consent. The Director of Nursing (DON) stated that incomplete informed consent is not valid, and medication should not be administered without it.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs and preferences of two residents by not ensuring their call lights were within reach. Resident 1, who was admitted with diagnoses including dementia, gait abnormalities, and muscle weakness, was found to have a call light on the floor, out of reach. Despite having a care plan and physician's order indicating the call light should be within reach due to a high risk of falls, staff did not comply with these directives. During an observation, a Licensed Vocational Nurse confirmed the call light was not properly positioned, which could prevent the resident from calling for assistance. Similarly, Resident 77, who also had dementia and was at high risk for falls, had a call light placed on the upper left side of the bed, not within reach. This resident required substantial assistance with activities of daily living and had limited upper extremity movement, making it difficult to activate the call light. The care plan and physician's order also specified that the call light should be within reach, but this was not adhered to by the staff. An observation confirmed the call light was not accessible, and the Licensed Vocational Nurse acknowledged the oversight. The facility's policy and procedure on answering call lights, which was last reviewed in January 2025, clearly stated that call lights should be within easy reach of residents when they are in bed or confined to a chair. However, the staff failed to follow this policy, resulting in a deficiency that could delay care and services for the residents involved.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide two residents, Resident 20 and Resident 84, with the option to formulate an advance directive, which is a legal document that outlines a person's wishes regarding medical treatment if they are unable to communicate. Resident 20 was admitted with conditions such as cardiomyopathy and COPD and had the capacity to understand and make decisions. However, the Social Services Director (SSD) did not offer or provide information about formulating an advance directive during the admission process, which is a requirement according to the facility's policy. The Director of Nursing (DON) confirmed that the admission department should initiate the conversation about advance directives, and the SSD should follow up, but this was not done for Resident 20. Resident 84, who was admitted with conditions including hemiplegia and encephalopathy, had a representative due to their inability to make medical decisions. The facility's records showed no evidence of an advance directive or acknowledgment of one in Resident 84's medical records. The Health Information Director (HID) and SSD confirmed that there was no documentation indicating that Resident 84's representative was informed about the option to formulate an advance directive. The SSD acknowledged that this oversight could lead to the resident's rights not being respected, as there was no paper form of the resident's after-life wishes. The facility's policy and procedure on advance directives, last reviewed in January 2025, states that residents should be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive upon admission. If a resident is incapacitated, this information should be provided to their legal representative. The policy also requires that any decision regarding advance directives be documented in the resident's medical record. However, this policy was not followed for Residents 20 and 84, leading to a violation of their rights.
Failure to Notify Resident Representative of Low Iron Level
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding notifying a resident's representative of a change in condition. Specifically, the facility did not promptly inform the representative of a resident who had a laboratory result indicating a low iron level. This oversight was identified for one of the two sampled residents, referred to as Resident 50, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, epilepsy, and hypertension. The resident's fluctuating capacity to understand and make decisions was noted, and the family member was designated as the resident representative. On January 23, 2025, Resident 50's lab results showed an iron level of 49 micrograms per deciliter, which is below the normal range. Despite this significant finding, there was no Situational Background Assessment and Recommendation (SBAR) completed, which is a structured communication tool used to report changes in a resident's condition. The Health Information Director confirmed the absence of an SBAR for the low iron result. The Minimum Data Set Coordinator Nurse also noted that an SBAR should have been completed to ensure proper interventions, monitoring, and communication with the resident's family. The Director of Nursing confirmed that the low iron level represented a change in the resident's condition that required an SBAR and subsequent care planning. However, no follow-up orders for labs or care plans were created, and the family was not informed of the change in condition. This failure to notify the family violated the resident representative's right to be informed, as outlined in the facility's policy and procedure for changes in a resident's condition or status.
Failure to Maintain Resident Record Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN 4) left an electronic health record (EHR) open and unattended. This incident involved Resident 92, who was admitted to the facility with a history of transient ischemic attack, hypertension, and hyperlipidemia. During a random observation, LVN 4 was seen standing outside Resident 92's room with the EHR open to the medication administration records. LVN 4 then walked away to Nurse Station 2, leaving the EHR open and unattended. In an interview, LVN 4 acknowledged leaving the EHR open and unattended, recognizing the risk of unauthorized access to Resident 92's personal information. The Director of Nursing (DON) confirmed that staff are required to minimize computer screens when leaving them unattended to protect resident information. The facility's policy on confidentiality and personal privacy, last reviewed in January 2025, mandates the protection and safeguarding of resident confidentiality and personal privacy, limiting access to authorized staff and business associates.
Failure to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident, identified as Resident 32, by not ensuring that the resident's floor mat was in proper condition. The floor mat, which was located on the right side of the resident's bed, had a torn lower right corner. This issue was identified during an observation and interview with a treatment nurse, who acknowledged the damage and stated that the maintenance department would be notified to replace the mat. The resident's care plan included the use of a floor mat as an intervention to prevent falls, and the physician's order required the mat to be monitored every shift for proper positioning and placement. Resident 32 had been admitted to the facility with diagnoses including muscle wasting, dementia, and generalized muscle weakness, and required total assistance with activities of daily living. The resident's cognitive abilities were severely impaired, necessitating a safe and supportive environment. The facility's policy on providing a homelike environment emphasized the importance of maintaining a clean, safe, and functioning environment for residents. The Assistant Director of Nursing confirmed that any equipment in disrepair should be reported immediately to ensure residents are provided with a safe and homelike environment.
Failure to Document and Assess Restraint Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 20, was free from the use of physical restraints without proper documentation and consent. Resident 20 was admitted with diagnoses including cardiomyopathy, chronic obstructive pulmonary disease, and generalized muscle weakness. Despite having the capacity to understand and make decisions, as indicated in the Internal Medicine Initial Evaluation, the resident's bed was positioned with the right side against the wall, which restricted their freedom of movement. This setup was not accompanied by an informed consent, a restraint assessment, or a care plan, which are necessary to ensure the safety and appropriateness of such an arrangement. Observations and interviews revealed that the resident was unaware of the reason for the bed's positioning and expressed a preference for it not to be so close to the wall. Staff members, including a Certified Nursing Assistant and a Licensed Vocational Nurse, were also unsure of the rationale behind the bed's placement. The MDS Coordinator confirmed the absence of required documentation, such as a restraint assessment and informed consent, which are crucial for evaluating the necessity and safety of restraints. The facility's policy on the use of restraints emphasizes that they should only be used for the safety and well-being of residents and after other alternatives have been tried unsuccessfully. The Director of Nursing acknowledged the lack of documentation and stated that the resident's preference was noted in a physician's order. However, the absence of a comprehensive assessment and care plan meant that the facility did not adhere to its own policy, which requires ongoing re-evaluation and documentation of restraint use. This deficiency had the potential to restrict the resident's freedom of movement and posed risks of physical and psychosocial harm.
Failure to Timely Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan in a timely manner for Resident 2, who was readmitted with a physician's order for heparin, an anticoagulant. Despite the order being dated 12/27/2024, the care plan addressing the use of heparin was not initiated until 1/21/2025. This delay was acknowledged by both the Registered Nurse and the Assistant Director of Nursing, who stated that care plans should be initiated as soon as a physician's order is received to ensure all staff are aware of the necessary interventions to prevent delays in care and treatment. Additionally, the facility failed to develop a comprehensive care plan for Resident 50, who was admitted with conditions including hemiplegia and epilepsy. On 1/23/2025, Resident 50's laboratory results indicated low iron levels, and a physician's order for ferrous sulfate was issued. However, no care plan was created to monitor for signs and symptoms of anemia or to address the risk of constipation associated with iron supplementation. Both the Minimum Data Set Coordinator Nurse and the Director of Nursing confirmed the absence of a care plan for this condition, emphasizing the importance of care plans in directing treatment and addressing health changes. The facility's policy and procedure on comprehensive person-centered care plans, last reviewed in January 2025, requires that such plans be developed within seven days of completing the required comprehensive assessment. The policy also mandates that care plans include measurable objectives and timeframes to meet residents' needs. The deficiencies in care planning for Residents 2 and 50 had the potential to delay necessary care and treatments, as the facility did not adhere to its own policy guidelines.
Failure to Update Care Plans for Medication and Insulin Changes
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident 32, after a physician increased the dosage of bupropion, a medication used to treat depression. The care plan, which was last updated in September 2023, did not reflect the change made in December 2024 when the dosage was increased from 100 mg to 150 mg. Interviews with the Assistant Director of Nursing (ADON), Director of Staff Development (DSD), and Minimum Data Set Nurse (MDSC) revealed that the care plan should have been updated to guide nurses on medication administration, but this was not done. Additionally, the facility did not update Resident 32's care plan for diabetes management to reflect current physician orders for insulin administration. The care plan, last revised in February 2023, did not include updated interventions for insulin types and dosages as ordered by the physician. The ADON acknowledged that the care plan should have been updated to ensure all staff were aware of the resident's current plan of care, which is crucial for preventing delays in necessary services. The facility's policy and procedure on care plans, last reviewed in January 2025, emphasizes the need for care plans to be comprehensive, person-centered, and updated as the resident's condition changes. However, the facility failed to adhere to this policy, resulting in care plans that did not accurately reflect the resident's current medical orders and interventions. This deficiency had the potential to delay the provision of necessary care and services to Resident 32.
Failure to Provide Meal Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with meals to Resident 67, who was diagnosed with hemiplegia, hemiparesis, moderate protein calorie malnutrition, and anemia. The resident was admitted and readmitted with these conditions, requiring a mechanical soft diet and feeding assistance at all times as per physician's orders. Despite these orders, the facility did not consistently provide the required assistance, as evidenced by multiple observations and interviews. Observations revealed that Resident 67 was often left without assistance during meals, leading to minimal food intake. On one occasion, the resident's food tray was left untouched, and on another, the resident consumed only two bites of breakfast. Interviews with staff and family members confirmed that Resident 67 required significant assistance and cueing to eat, yet the resident's name was not consistently listed on the staff assignment sheets as needing meal assistance. The Director of Nursing acknowledged that the resident required feeding assistance at all times, as per the physician's order, and that failure to provide this assistance could result in the resident not eating. The facility's policies on activities of daily living and dining assistance were not adhered to, as they state that residents unable to carry out these activities independently should receive necessary services to maintain good nutrition. This deficiency had the potential to lead to weight loss and further health complications for Resident 67.
Failure to Create SBAR for Resident's Low Iron Level
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when an SBAR was not created for a resident who experienced a change of condition due to low iron laboratory results. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, epilepsy, and hypertension, had a laboratory result indicating a low iron level of 49 ug/dL, which was below the normal range. Despite the laboratory results being communicated to the Nurse Practitioner and new orders for ferrous sulfate being carried out, the required SBAR was not created to document and monitor the resident's condition. Interviews with the Health Information Director, the Minimum Data Set Coordinator Nurse, and the Director of Nursing confirmed that an SBAR should have been created to address the resident's low iron level. The facility's policy and procedures indicated that changes in a resident's condition should be promptly documented and communicated to the relevant parties. The absence of an SBAR meant that the resident's condition was not adequately monitored, which could have included observing for symptoms such as fatigue, tarry stools, skin color changes, and bleeding.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident, identified as Resident 67, who was at risk of malnutrition and dehydration. The resident, who had a history of hemiplegia, hemiparesis, moderate protein-calorie malnutrition, and anemia, was not provided with the necessary assistance during meals on multiple occasions. Specifically, the resident was not assisted with meals on two consecutive days, which contributed to the resident consuming less than 50% of their meals on several occasions. This lack of assistance was contrary to the resident's care plan, which indicated the need for meal assistance due to swallowing safety concerns. Additionally, the facility failed to notify the resident's medical doctor when the resident consumed less than 50% of their meals for two consecutive meals on multiple dates. The facility's policy required that the medical doctor be informed in such cases to potentially adjust the resident's care plan, including orders for laboratory tests, fluids, diet changes, or medications. The failure to report these instances to the medical doctor posed a risk of weight loss and malnutrition for the resident, which could affect their overall health, including skin integrity, hydration, and consciousness levels. Interviews with staff and family members revealed inconsistencies in the facility's communication and documentation practices. The resident's need for meal assistance was not consistently reflected in staff assignments, leading to a lack of support during meals. Staff members acknowledged the oversight and indicated that the resident's meal consumption should have been reported to the medical doctor as per the care plan. The Director of Nursing confirmed that the lack of reporting and assistance could result in a delay in care, highlighting the facility's failure to adhere to its policies and procedures regarding nutritional support and monitoring.
Failure to Conduct Behavioral IDT Meetings for Medication Review
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident, identified as Resident 78, by not conducting a behavioral interdisciplinary team (IDT) meeting regarding the use of Seroquel and escitalopram. Resident 78 was admitted with diagnoses including toxic encephalopathy, unspecified dementia, and depression. The care plans for antidepressant and psychotropic medication use required discussions with the physician and family about the ongoing need for these medications. However, the facility did not document any IDT meetings with the psychiatrist to review the resident's medication use. The resident's psychoactive summary sheet indicated multiple behavioral episodes over two months, yet there was no evidence that these behaviors were discussed in the behavior management meetings. The facility's policy required periodic reviews of the relevance of each resident's medications and monitoring for improvement in target symptoms, but this was not documented for Resident 78. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed the lack of documentation and the importance of IDT meetings to adjust medication dosages appropriately. The facility's policy on psychotropic/antipsychotic medications emphasized the need for gradual dose reduction and behavioral interventions unless clinically contraindicated. Despite this, the facility did not conduct the necessary IDT meetings to evaluate the effectiveness of Resident 78's medications. The failure to hold these meetings and document discussions with the psychiatrist potentially compromised the resident's care and the ability to adjust medications based on behavioral changes.
Failure to Act on Pharmacist Recommendations and Medication Irregularities
Penalty
Summary
The facility failed to act upon the recommendations of the consultant pharmacist for a resident reviewed for unnecessary medications and medication regimen review. The resident, who was taking amiodarone for atrial fibrillation, did not have a thyroid stimulating hormone (TSH) blood draw ordered or conducted, despite the consultant pharmacist's recommendation. The MDS Coordinator confirmed that there was no TSH blood draw ordered from December 2024 to February 2025, and there was no documentation that the medication regimen review was relayed to the resident's physician. Another deficiency was identified when the facility failed to identify and report irregularities in the drug regimen for a resident using anticoagulants. The resident's physician's order and medication administration record did not match the heparin label, and the medication was administered without clarifying the discrepancy with the physician. The registered nurses involved acknowledged the error and stated that the medication should have been held until clarification was obtained. The consultant pharmacist and registered nurses involved in the medication regimen review process did not identify or report the irregularities in the residents' medication regimens. The facility's policy and procedure for medication regimen reviews were not followed, leading to potential risks for the residents involved.
Failure to Obtain Informed Consent for Psychotropic Medication Dosage Increase
Penalty
Summary
The facility failed to obtain informed consent for a resident when the dosage of bupropion, a medication used to treat depression, was increased. The resident, who was admitted with diagnoses including metabolic encephalopathy, generalized muscle weakness, and depression, was found to have severely impaired cognitive skills and lacked the capacity to make decisions. Despite this, the facility increased the resident's bupropion dosage from 100 mg to 150 mg without obtaining the necessary informed consent, as required by the facility's policy. Interviews with the Assistant Director of Nursing, Director of Staff Development, and Director of Nursing confirmed that informed consent should have been obtained with any increase in psychotropic medication dosage. The facility's policy mandates that written informed consent be recorded in the resident's medical record before initiating treatment with psychotherapeutic drugs. The failure to obtain informed consent for the increased dosage of bupropion was acknowledged by the facility staff, highlighting a lapse in adhering to the established protocol for resident rights and medication administration.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69 percent. This was due to two medication errors affecting two residents. The first error involved a Licensed Vocational Nurse (LVN) administering potassium chloride to a resident with only two ounces of water, contrary to the physician's order which specified a full glass of water. This resident had a history of Parkinson's Disease, hypokalemia, and essential hypertension. The LVN acknowledged the mistake and the Director of Nursing confirmed that the facility's policy required adherence to physician orders. The second error involved another LVN administering heparin to a resident without clarifying the physician's order, which did not match the medication label. The resident had a history of encephalopathy, complete atrioventricular block, and dementia. The physician's order lacked a specified route of administration, and the LVN failed to consult with a registered nurse or physician before proceeding. The Assistant Director of Nursing noted that the LVN should have clarified the order, as the route of administration is a critical component of medication safety. Both errors were observed during medication administration and were confirmed through interviews with nursing staff and a review of facility policies. The facility's policy on medication administration emphasized the importance of following prescriber's orders and verifying the correct medication details before administration. These deficiencies highlighted lapses in following established procedures, potentially leading to adverse effects for the residents involved.
Failure to Follow Menu and Meet Nutritional Needs
Penalty
Summary
The facility failed to adhere to the prescribed menu and did not meet the nutritional needs of a resident, identified as Resident 38, who was at nutritional risk due to a diagnosis of adult failure to thrive. The resident's care plan required adherence to a diet as ordered and consideration of food preferences. On a specific date, the facility's menu included green beans as part of the dinner meal, but due to a delivery issue, spinach was initially substituted. However, when spinach ran out, corn was served instead without prior approval from the Registered Dietitian (RD) and without considering Resident 38's dislike for corn. The Dietary Supervisor (DS) acknowledged the substitution error and the lack of communication regarding Resident 38's food preferences. The RD confirmed the substitution of corn for spinach but was unaware of the resident's refusal to eat corn, which could affect the resident's food intake. The facility's policies required that any menu deviations be documented and that residents' likes and dislikes be considered when making substitutions, which was not followed in this instance.
Inaccurate Documentation of Blood Pressure in Resident's MAR
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, identified as Resident 20, which led to potential confusion in care. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and unspecified cardiomyopathy. A discrepancy was found in the resident's medical records, specifically in the Medication Administration Record (MAR) for January 2025. The MAR indicated that a Licensed Vocational Nurse (LVN) administered Sacubitril-Valsartan with a documented blood pressure of 18/62, which was inaccurate. The LVN later stated that the correct blood pressure should have been documented as 118/62. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the LVN should have rechecked the blood pressure and corrected the documentation. The facility's policy on charting and documentation, last reviewed in January 2025, requires that documentation in the medical record be objective, complete, and accurate. The inaccurate documentation could have led to improper administration of medication, as the physician's order specified holding the medication for systolic blood pressure less than 110.
Failure to Involve Resident in Hospice Care Planning
Penalty
Summary
The facility failed to ensure necessary care was provided consistently for a resident reviewed for hospice services. The deficiency involved the lack of documented evidence that the resident and/or their representative was involved during the initial interdisciplinary team (IDT) meeting for admission to discuss the hospice plan of care. This oversight had the potential to negatively affect the resident's physical comfort and psychosocial well-being by delaying or lacking necessary hospice care and services. The resident in question was originally admitted to the facility and later readmitted with diagnoses including Parkinson's disease, dementia, and osteoarthritis. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for substantial assistance with activities of daily living. Despite receiving hospice services, there was no indication that the resident or their representative participated in the IDT meeting, which is crucial for developing a comprehensive care plan. Interviews with facility staff, including the Social Services Director and the Assistant Director of Nursing, confirmed that the IDT meeting did not include the resident or their representative. The facility's policy and procedure emphasized the importance of involving the resident and their representative in care planning, yet this was not adhered to in this case, leading to the deficiency.
Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to monitor a resident for the use of vancomycin, an antibiotic, which could have led to unidentified side effects. The resident, who was admitted with diagnoses including metabolic encephalopathy, pneumonia, and unspecified cardiomyopathy, was prescribed vancomycin intravenously every 12 hours for pneumonia. Despite the administration of the medication being documented, there was no recorded monitoring for side effects or effectiveness in the Medication Administration Record, Progress Notes, or Daily Skilled Medicare Charting during specific shifts. Interviews with the Infection Preventionist, Director of Staff Development, and Director of Nursing revealed that the facility's policy required antibiotic monitoring every shift, with documentation in the Progress Notes and other records. However, this monitoring was not performed as required, and the facility's policies on antibiotic stewardship and infection surveillance were not followed. The lack of documentation and monitoring was acknowledged by the staff, highlighting a deficiency in the facility's adherence to its own procedures for antibiotic use and monitoring.
Failure to Maintain Safe Equipment for Resident
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically for one resident whose bed controller cable was observed to have a chipped part at the base with exposed screws. This deficiency was identified during an observation and interview with a treatment nurse, who acknowledged the issue and stated that the maintenance department was responsible for addressing such equipment disrepair. However, the nurse was unsure of the maintenance department's schedule for checking rooms, and it was noted that staff were responsible for notifying maintenance of any equipment issues. Interviews with the Assistant Director of Nursing and the Maintenance Supervisor revealed that the facility's policy required immediate notification to the maintenance department for any broken equipment. The Maintenance Supervisor confirmed that regular rounds were conducted to check equipment, but staff were expected to report any issues. The facility's policies emphasized providing residents with a safe, clean, and homelike environment, yet the failure to address the damaged bed controller in a timely manner posed a risk of injury to the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Survey Agency (SSA) and the Ombudsman. This deficiency involved a resident who was admitted with diagnoses including unspecified atrial fibrillation, essential hypertension, and Alzheimer's disease. The resident was noted to have severe cognitive impairment and was dependent on staff for all activities of daily living. On January 7, 2025, minor bruising and swelling were observed on the resident's left hand, and the physician was notified. However, the allegation of abuse was not reported to the SSA and Ombudsman until the following day. The incident began when a caregiver noticed redness on the resident's hand and reported it to a CNA, who then informed an LVN. The family member of the resident later expressed concerns that the resident might have been mishandled by staff. Despite these concerns being communicated to the nursing staff, the Director of Nursing was not informed of the situation on the day it occurred. The facility's policy requires that any suspicion of abuse be reported immediately to the administrator and relevant authorities, but this protocol was not followed. Interviews with staff revealed a breakdown in communication and reporting procedures. The Director of Nursing and the Administrator were not notified in a timely manner, and the report to the SSA was delayed until the morning after the incident was first observed. The facility's policy mandates immediate reporting of abuse allegations, defined as within two hours for incidents involving abuse or serious bodily injury, which was not adhered to in this case.
Failure to Follow Physician's Orders for Pain Management
Penalty
Summary
The facility failed to provide pharmaceutical services by not adhering to the physician's orders for a resident, which could have led to an overdose. The resident, who was admitted with conditions including unspecified atrial fibrillation, essential hypertension, and Alzheimer's disease, was dependent on staff for all activities of daily living and had severely impaired cognitive skills. The care plan for the resident included administering pain medication as ordered, with specific instructions for different pain levels. However, a Licensed Vocational Nurse administered two tablets of hydrocodone-acetaminophen for a pain level of seven, contrary to the physician's order, which specified ibuprofen for moderate pain levels of four to six. This action was confirmed during a review with the Director of Nursing, who acknowledged that the nurse did not follow the physician's order. The facility's policy on administering medications emphasized that medications must be administered as prescribed, which was not followed in this instance.
Failure to Ensure Call Lights Within Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, both of whom were at high risk for falls. Resident 3, admitted with diagnoses including metabolic encephalopathy, essential hypertension, and type 2 diabetes mellitus, was found to have a severely impaired cognitive status and a high fall risk score. Despite the care plan intervention specifying that the call light should be within reach, it was observed hanging on the television rack, out of the resident's reach. The Assistant Director of Nursing (ADON) confirmed that the call light was not accessible, which could prevent the resident from calling for assistance, potentially leading to unassisted standing and falls. Similarly, Resident 2, admitted with acute cerebrovascular insufficiency, essential hypertension, and anxiety disorder, also had a severely impaired cognitive status and was at high risk for falls. The care plan required the call light to be within reach, but it was found wedged between the mattress and bedside rails, making it invisible and inaccessible to the resident. The ADON and Director of Nursing (DON) acknowledged that the call light's inaccessibility could delay care and assistance for the resident, indicating a failure to meet the residents' needs for assistance as per the facility's policy.
Failure to Provide Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary care to prevent accidents and minimize injuries for a resident identified as high risk for falls. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, age-related osteoporosis, and essential hypertension, was assessed with moderately impaired cognitive skills and required moderate assistance. Despite a fall risk assessment indicating a high risk for falls, the facility did not provide fall mats on both sides of the resident's bed. Observations revealed that the resident's overbed table was placed on top of the fall mat on one side, leaving the other side without a mat, which posed a risk of falls and potential injury. Additionally, the facility failed to consistently communicate the resident's fall risk to staff. The huddle reports, which are intended to inform staff of residents' specific needs, were inconsistent, with multiple days not identifying the resident as high risk for falls. Interviews with staff, including a CNA, LVN, and the DON, confirmed the lack of proper communication and the absence of fall mats on both sides of the bed. The facility's policy on managing falls and fall risk emphasized the need for interventions based on assessments, but these were not adequately implemented for the resident.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide the requested medical records for a resident when a request was received. The resident, who was admitted with diagnoses including heart failure, had severe cognitive impairment as indicated in the Minimum Data Set. The request for the resident's medical records was made, but the facility did not fulfill it in a timely manner. The Medical Records Director confirmed the delay and acknowledged that this failure potentially violates facility policy. The Director of Nursing also confirmed the failure to issue the requested documents promptly. The facility's policy, last revised in 2009, states that residents should have access to their records within 72 hours of a request, excluding weekends and holidays.
Resident Dignity Compromised by Inappropriate Staff Behavior
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a transportation attendant and a resident. The resident, who was admitted with end-stage renal disease, generalized muscle weakness, and mobility issues, was returning from dialysis when a transportation attendant yelled 'You shut up!' at them. This incident was witnessed by a Licensed Vocational Nurse (LVN), who confirmed the inappropriate behavior. The resident, who was fully alert and capable of decision-making, reported feeling afraid of potential abuse following the encounter. Interviews with nursing staff, including a Registered Nurse (RN), highlighted that such behavior is unacceptable, especially given the vulnerability of the residents due to their health conditions. The facility's policy on resident rights, which emphasizes the importance of treating residents with respect, kindness, and dignity, was not adhered to in this instance. The incident had the potential to cause emotional distress and a loss of dignity for the resident involved.
Failure to Implement Person-Centered Care Plan for Dietary Compliance
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes for a resident who was noncompliant with a physician-ordered diet. The resident, who was admitted with diagnoses including unspecified sepsis, generalized muscle weakness, and Charcot's joint, had intact cognitive skills and required moderate assistance for activities of daily living. Despite having a physician's order for a carbohydrate-controlled, no added salt regular texture diet, the resident preferred to order and buy food from outside the facility, which was not addressed in their care plan. Interviews with facility staff revealed a lack of awareness and action regarding the resident's dietary noncompliance. The Dietary Supervisor was unaware of the resident's outside food orders, and the Assistant Director of Nursing acknowledged the absence of a care plan addressing the resident's preference for outside food. The facility's policies required staff to be aware of and approve foods brought in by residents or visitors to ensure compliance with prescribed diets, but this was not followed. Additionally, the facility's procedures for comprehensive assessments and care delivery were not adequately implemented, contributing to the deficiency.
Resident Left Facility Unsupervised Without Physician's Order
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for going out on pass before allowing the resident to leave the facility unsupervised. The resident, who was admitted with diagnoses including unspecified sepsis, generalized muscle weakness, and right ankle and foot Charcot's joint, had the capacity to understand and make decisions. The resident required moderate assistance for activities of daily living and was occasionally incontinent. Despite these needs, the resident left the facility unsupervised multiple times without a documented expected time of return, and there was no physician's order for these outings. Interviews and record reviews revealed that the facility's policy required a physician's order for a resident to go out on pass. However, the resident left the facility unsupervised on several occasions, and the nursing staff failed to document the times of departure and return. The Assistant Director of Nursing acknowledged the lack of documentation and the absence of a physician's order, which placed the resident at risk for accidents. The facility's policy and procedure emphasized the need for a physician's order before allowing a resident to leave unsupervised, which was not followed in this case.
Failure to Enforce Masking Policy for Transport Personnel
Penalty
Summary
The facility failed to implement proper infection control measures when a transporter did not wear a facemask while picking up a resident for an appointment. This incident occurred despite the facility having a policy requiring all staff and transport personnel to wear facemasks inside the facility, especially after a staff member tested positive for COVID-19 two days prior. The transporter entered the facility through the back entrance and was not informed of the masking requirement, leading to a potential risk of spreading COVID-19 among residents and staff. The resident involved was admitted to the facility with diagnoses including toxic encephalopathy, diabetes mellitus, and unspecified dementia. The resident's cognitive skills for daily decisions were severely impaired, as indicated in their Minimum Data Set. The incident was observed by an LVN, who then provided the transporter with a facemask. The Infection Preventionist confirmed the facility's masking policy and acknowledged the positive COVID-19 case among staff, emphasizing the importance of adhering to infection control protocols.
Failure to Provide Necessary Respiratory Care and Services
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents by not ensuring that their oxygen tubings were dated when changed and that the tubing was free from kinks. Resident 2, who was admitted with interstitial pulmonary disease, dementia, and essential hypertension, had an oxygen cannula observed on their chest instead of their nose, and the oxygen tubing was kinked. Additionally, the oxygen tubing and cannula were not labeled with the date they were replaced, and there was no oxygen supplies bag at the bedside. The Registered Nurse (RN) confirmed that the kinked tubing could result in the resident receiving less oxygen and that undated supplies could lead to infections. The facility's policy required oxygen supplies to be replaced every 7 days and as needed, but this was not followed for Resident 2. Resident 3, admitted with pulmonary embolism, acute cor pulmonale, respiratory failure with hypoxia, and pulmonary hypertension, also had undated oxygen tubing. The RN was unable to state the facility's policy on the care of residents with oxygen. The Director of Nursing (DON) confirmed that the facility policy required all oxygen or respiratory supplies to be replaced every 7 days and as needed, and acknowledged that the facility failed to label the oxygen supplies and tubing with the date they were replaced for both residents.
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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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