Vernon Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s failure to recognize and respond to a change of condition related to a resident’s generalized itchy rash, to provide treatment, and to communicate this condition to the receiving hospital. The resident, who had diagnoses including schizophrenia, cardiomegaly, and chronic kidney disease and whose H&P noted fluctuating capacity to understand and make decisions, was readmitted to the facility with generalized itchy rashes over the whole body. A progress note dated 1/10/2026 documented the readmission with generalized itchy rashes, and a skin check on the same date recorded a rash on the abdomen, cervical region, and bilateral front and back thighs, marked as a new issue to be tracked. Despite this documentation, no Change of Condition (COC) form was initiated, and the physician was not notified as required by facility policy. Subsequent documentation and interviews showed that the rash continued without appropriate assessment or treatment. A multidisciplinary care conference (IDT) dated 1/13/2026 contained no indication of the rash or any medical treatment for the generalized itching. A follow-up skin check dated 1/15/2026 again documented the rash in the same areas and indicated it should be tracked and reviewed, yet the resident was not monitored for the rash between 1/11/2026 and 1/15/2026, and no treatment was initiated. The Treatment Nurse stated that the situation represented a COC and that the physician should have been notified so medical treatment could be started, and also acknowledged that staff would not know if the rash was improving or worsening due to lack of monitoring. The Infection Preventionist similarly stated that the resident should have been treated prophylactically and that there was no COC, no monitoring for symptoms, and no treatment for itching. When the resident was transferred to a General Acute Care Hospital on 1/15/2026, the facility’s discharge summary (SNF/NF to Hospital Transfer Form) indicated that the resident had no skin issues, despite prior documentation of a generalized rash. Hospital records from the same date documented a generalized rash over the whole body, and by 1/17/2026 the hospital had placed the resident on isolation precautions for scabies. The Treatment Nurse and a Registered Nurse both stated that licensed staff were expected to provide a complete report to the hospital, including skin conditions, and acknowledged that the rash was not communicated, characterizing this as poor communication. Facility policies on Prevention and Management of Scabies required examination for signs and symptoms of scabies on admission, isolation of undiagnosed and untreated rashes, and notification of the DON for suspicious rashes, while the Change of Conditions policy required physician notification, assessment, SBAR communication, and documentation every 72 hours for significant changes. These policy requirements were not followed in the resident’s case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document a change of condition (COC) assessment for a resident who refused psychotropic medications. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy, was noted to have severe cognitive impairment and required assistance with activities of daily living. Despite the resident's repeated refusal of medications on multiple occasions, the licensed vocational nurse (LVN) only documented the refusal but did not complete a COC assessment as required by facility policy. The LVN acknowledged that medication refusal constituted a change in condition and should have been documented accordingly. Interviews with the resident confirmed ongoing refusal of medications, and the Director of Nursing (DON) verified that no COC assessment was completed in response to these refusals. Facility policy required licensed nurses to assess changes in condition, determine appropriate interventions, and notify the resident's physician and legal representative or family member in the event of untoward responses to medications. The lack of a documented COC assessment meant that the resident's current condition and behavior were not properly monitored as per policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a person-centered care plan for a resident who consistently refused to take prescribed medications. During observation and interviews, the resident was noted to refuse medications, stating they did not need them, despite having diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy. The resident's medical records indicated severe cognitive impairment and a need for supervision or assistance with activities of daily living. Physician orders documented multiple medications for mental health and seizure management, but there was no care plan addressing the resident's medication refusals. Staff interviews confirmed that the resident routinely refused medications and that facility policy required a care plan to be developed in such cases. The LVN and DON both acknowledged that a care plan should have been created to address the refusals, and the facility's policy specified that care plans must be updated based on assessed needs. Despite these requirements, no care plan was in place to guide staff in managing the resident's medication refusals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely administration of medications for three of six sampled residents. For one resident with schizoaffective disorder, major depressive disorder, and hypertension, medications such as lithium carbonate, lisinopril, risperdal, and gabapentin were not administered at the scheduled times, with documentation showing administration occurred significantly later than ordered. Another resident with schizophrenia, type 2 diabetes, and hypertension also experienced delays in receiving medications including empagliflozin, metformin, lisinopril, and risperdal, with records indicating these medications were given well after the scheduled times on multiple days. A third resident with schizoaffective disorder, epilepsy, and dementia had similar delays in receiving levetiracetam, memantine, haloperidol, and divalproex sodium, as shown by medication administration records and audit reports. Interviews with licensed vocational nurses confirmed that medications were administered more than one hour after the scheduled times, which was acknowledged as contrary to facility protocol and physician orders. The nurses stated that medications should be given within one hour before or after the scheduled time, and that delays occurred when residents initially refused medications or due to other factors. The actual times of administration were not always accurately documented, and staff recognized that such delays could affect residents' moods and symptoms. Additionally, the facility failed to maintain complete and accurate controlled drug count records for two of three medication carts. Reviews of the narcotic count sheets revealed multiple blank, unsigned spaces where licensed nurses had not signed at shift changes, as required by facility policy. Interviews with nursing staff confirmed that the count sheets should be signed at every change of shift after narcotics are counted, and that missing signatures indicated a lapse in accountability for controlled substances.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses including liver cirrhosis, COPD, and bipolar disorder was transferred to a general acute care hospital (GACH) for altered mental status. The resident was cleared for return to the facility by the hospital, but the facility repeatedly denied readmission, citing a lack of available male beds. However, facility records indicated that a male bed was available on several dates during the period in question. The facility's Admission Director (AD) acknowledged receiving multiple inquiries from the hospital's discharge planner regarding bed availability and confirmed that the resident was denied readmission by the Administrator (ADM) without a clear reason. The Director of Nursing (DON) stated that the facility could meet the resident's needs and that there was no justification for denying readmission, even after the expiration of the seven-day bed hold period. The resident remained in the hospital for 14 days beyond the initial discharge date due to the facility's refusal to readmit. A review of facility policies indicated that residents previously admitted to the facility should be readmitted when eligible, and that Medi-Cal/Medicaid eligible residents should be readmitted to their previous room or the first available bed in a semi-private room if hospitalized for more than seven days. Despite these policies and available beds, the facility did not readmit the resident, resulting in a prolonged hospital stay.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain and document informed consent for the use of psychotropic medications for one resident with diagnoses including cognitive communication deficit, anxiety, and dementia. The resident had severely impaired cognition and was dependent on staff for all activities of daily living. Multiple physician orders for lorazepam, an anti-anxiety medication, were issued with varying dosages, frequencies, and routes of administration over several months. However, there was no documented informed consent for several of these orders, specifically for those dated 6/15/2025 to 6/16/2025 and 7/13/2025 to 7/21/2025, as confirmed by the Medical Records Director. The only informed consent obtained in 2025 was for a later order starting 7/22/2025. Interviews with facility staff, including the Medical Records Director and the Director of Nursing, confirmed that informed consents should be stored in the electronic medical record and that new consents are required when there is a change in the frequency or route of psychotropic medication administration. Facility policy also requires written informed consent for psychotropic medications, to be renewed every six months and placed in the resident's medical record. Despite these policies, the required consents were not present for the specified medication orders, resulting in a failure to ensure the resident or their responsible party was informed about the medication's use and potential adverse effects.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an as-needed (PRN) psychoactive medication order for a resident did not exceed the facility's policy limit of 14 days. The resident, who had diagnoses including cognitive communication deficit, anxiety, and dementia with severely impaired cognition and total dependence on staff for activities of daily living, was initially prescribed lorazepam for agitation for 14 days. After the initial order was discontinued, a new order was placed for lorazepam every 6 hours PRN for 30 days, despite the absence of documented behaviors indicating agitation at the time of the new order and no documented rationale from the prescribing provider for exceeding the 14-day limit. Review of the resident's records showed that the extension to 30 days was requested by an LVN, not the psychiatric provider, and there was no documentation from the provider supporting the need for prolonged administration. The facility's policy required that any PRN psychoactive medication order not exceed 14 days unless the physician documented a reason for continued use. Interviews with staff confirmed that the extension was not justified by an increase in the resident's agitation or by provider documentation, and that it was outside the LVN's scope to request such an extension.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct an Interdisciplinary Team (IDT) meeting, a fall risk evaluation, and a post-fall evaluation for a resident following an unwitnessed fall. The resident, who had diagnoses including cognitive communication deficit, anxiety, and dementia, was noted to have severely impaired cognition and was dependent on staff for all activities of daily living. After the resident experienced an unwitnessed fall and sustained a skin tear, staff did not complete the required fall risk evaluation or post-fall evaluation, nor did they convene an IDT meeting as outlined in facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the necessary assessments and team review were not performed after the fall. The facility's policy required a new fall risk evaluation, a post-fall evaluation, and an IDT review with documentation following any fall. The absence of these actions was acknowledged by staff and leadership, and it was noted that these steps are intended to identify risk factors and update the care plan to prevent further incidents.

Penalty

Fine: $19,115

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with hemiplegia and hemiparesis affecting the left side, who required moderate assistance for transfers and was dependent on staff for activities of daily living, was not provided the necessary care and services as outlined in their comprehensive assessment and care plan. On one occasion, the resident called for a CNA to assist with transferring from a wheelchair to bed. The CNA instructed the resident to get out of the chair and do it himself, then left the room without providing assistance. The resident, unable to safely transfer independently, attempted the transfer alone and subsequently fell from the wheelchair. The facility failed to implement the resident's At Risk for Falls Care Plan, which required staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. The care plan did not specify interventions for transfer assistance, despite the resident's documented need for moderate help. Additionally, the facility did not follow its own Abuse - Prevention, Screening, & Training Program policy, which defines neglect as the failure to provide necessary goods and services to maintain a resident's well-being and avoid harm or distress. Following the fall, the resident reported pain to the face and emotional distress, and was later transferred to a general acute care hospital for further evaluation. Medical records from the hospital indicated the resident was diagnosed with generalized anxiety disorder and had difficulty ambulating due to musculoskeletal weakness. The incident was reported to facility staff, and interviews confirmed the sequence of events leading to the resident's fall and subsequent injury.

Penalty

Fine: $19,115

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia, depression, and anxiety disorder, who also had a history of aggressive behavior. The Minimum Data Set (MDS) assessment for this resident did not accurately reflect the resident's history of aggressive physical and verbal behavior, despite multiple documented incidents of aggression and disruption. The care plan for the resident was not individualized or effective, lacking specific interventions, supervision details, and frequency of re-evaluation. There was also a period when no behavior or schizophrenia care plan was in place for the resident. Multiple documented incidents showed the resident displaying aggressive and disruptive behaviors, including provoking other residents, yelling, and physically assaulting staff. On one occasion, the care plan addressing behavior problems was canceled, and for nearly two weeks, there was no care plan in place to address the resident's behavioral health needs. The MDS assessment contradicted the clinical record by indicating the resident did not exhibit physical or verbal behaviors toward others, despite clear evidence to the contrary in the clinical documentation. The lack of an accurate assessment and an effective, individualized care plan led to an incident where the resident entered another resident's room, resulting in a physical altercation. The resident struck another resident in the chest and required administration of multiple medications for aggressive behavior. Staff interviews confirmed that documentation of the resident's behavior was insufficient and that the interventions in place were not appropriate or effective for the resident's needs. Facility policies required comprehensive, person-centered care planning and prompt action to prevent resident-to-resident altercations, but these were not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.

Removal Plan

• The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
• The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
• The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
• The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
• For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
• For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
• Discharge planning will begin on the residents' admission to the facility.
• The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
• The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
• The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
• The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
• The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
• The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
• The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
• The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
• The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
• Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its Fall Management Program policy and procedure by not conducting and initiating an Interdisciplinary Team (IDT) meeting after each of three falls sustained by a resident. The policy required the IDT to review and update the resident's fall risk status and care plan upon identification of a significant change of condition post-fall. Despite this requirement, the IDT meetings were not held after each fall, as acknowledged by the Director of Nursing (DON), and the care plan was not appropriately updated to address the resident's ongoing fall risk. The resident involved had a history of muscle weakness, abnormal gait, mobility issues, and alcoholic cirrhosis. Upon admission, the resident was identified as high risk for falls, with a fall risk score of 19.0, and required moderate assistance with activities of daily living. The resident experienced three falls within a short period, each documented in the medical record. After each fall, care plans were updated with interventions such as neuro checks, floor mats, and physical therapy consults, but the required IDT meetings to review the circumstances and revise the care plan were not conducted. Additionally, there were inaccuracies in the documentation of the resident's fall risk scores following each incident, with the scores decreasing despite repeated falls. The DON confirmed that these inaccuracies were due to incorrect information entered into the computer system. The failure to conduct IDT meetings and maintain accurate fall risk assessments resulted in the resident continuing to experience falls, with the potential for life-threatening injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement treatment orders for skin lesions for one resident by not ensuring that physician orders were transcribed into the resident's treatment administration record. The resident, who was admitted with diagnoses including Parkinson's Disease, paranoid schizophrenia, and systemic involvement of connective tissue, had severely impaired cognition. The Wound Assessment and Plan indicated specific treatment orders for lesions on the resident's forehead and right ocular region, but these orders were not found in the Order Summary Report or documented in the Treatment Administration Record (TAR) for the relevant months. Interviews with the Treatment Nurse and the Director of Staff Development revealed that the orders for the resident's skin lesions were not entered into the electronic medical record (EMR), and there was no documentation of the treatments being performed. The facility's policy and procedure required that treatments administered be documented in the resident's medical record, and that medication and treatment orders be transcribed onto the appropriate administration record. The lack of documentation and transcription of orders placed the resident at risk of not receiving appropriate skin treatment and caused a delay in communication between licensed staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its Abuse-Prevention, Screening, and Training Program policy, resulting in an incident where Resident 2 hit Resident 1 in the face. Resident 1, who was diagnosed with schizophrenia and anxiety disorder, was independent in daily activities and had intact cognitive skills. The incident occurred while Resident 1 was using the phone, and Resident 2, who had a history of schizophrenia and major depressive disorder with moderately impaired cognitive skills, approached and hit Resident 1. Resident 2's care plan required a 1:1 sitter to intervene as necessary to protect others, but the sitter was not close enough to prevent the incident. The Director of Nursing acknowledged that the staff failed to provide appropriate supervision, as the sitter was not maintaining a safe distance to effectively monitor Resident 2, who had a tendency to pace with aggressive behavior. The facility's policy clearly stated that no form of resident abuse or neglect was condoned, and physical abuse included actions such as hitting. The failure to adhere to the policy and provide adequate supervision led to the incident, compromising the safety and rights of the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to monitor the behaviors of a resident who was prescribed psychotropic medications, which are used to treat psychiatric conditions by altering brain chemistry. The resident, who had diagnoses of schizophrenia and major depressive disorder, was prescribed Depakote, Invega Sustena, and Risperdal for mood disorder, aggressive behavior, and auditory hallucinations, respectively. However, there was no documented evidence of monitoring the resident's behaviors, such as labile mood, aggressive behavior, and auditory hallucinations, as required by the facility's policy. The Director of Nursing acknowledged the absence of documentation and emphasized the importance of monitoring to assess medication effectiveness and evaluate behavioral changes. The facility's policy on Behavior/Psychoactive Medication Management required monthly documentation of behavior occurrences and adverse reactions, but this was not adhered to in the case of the resident. The lack of behavior monitoring placed the resident at risk of not receiving necessary interventions for increased psychiatric behaviors and was considered inappropriate medication management. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing, who confirmed the failure to document and monitor the resident's target behaviors as per the facility's procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper food storage and handling practices, as observed during a survey. In the walk-in refrigerator, three tomatoes were found with rotten spots, which the Dietary Supervisor (DSS) acknowledged should be discarded due to mold presence that could potentially make residents sick. Additionally, two pitchers of mixed lemonade and a package of powdered lemonade mix were improperly stored on the sink at the sanitizer/detergent mixing area, posing a risk of chemical contamination. The DSS confirmed that food should not be stored near chemicals to prevent mix-ups that could lead to resident illness. Furthermore, the coffee machine was found to have buildup in the sight glass tube, which the DSS indicated could harbor mold and pose a health risk to residents. The facility's policy and procedure on Food Storage and Handling, dated June 2024, mandates that cleaning supplies be stored separately from food and that fresh fruit be checked for ripeness and ordered frequently to ensure freshness. These observations highlight the facility's failure to adhere to its own policies, potentially leading to foodborne illnesses among residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors by not administering medications as ordered over a period from December 1, 2024, to January 9, 2025. The resident, who was admitted on December 17, 2024, had multiple diagnoses including parkinsonism, hepatic encephalopathy, diabetes mellitus, schizophrenia, epilepsy, anxiety, and depression. The resident's Minimum Data Set indicated severely impaired cognitive skills and dependency for activities of daily living, with routine antipsychotic medication use. The deficiency involved the failure to administer several medications as prescribed, including fluvoxamine maleate, pantoprazole sodium, demeclocycline HCL, risperidone, Vascepa, and lactulose. The Medication Administration Record (MAR) showed multiple instances where medications were not given, marked by the number '9' in the MAR box, indicating non-administration. Progress notes revealed that medications were often not available and were awaiting pharmacy delivery, leading to missed doses. During an interview and observation with the Director of Nursing (DON) and a Registered Nurse (RN), it was found that some medications were available in the medication cart but were not administered due to being stored in different drawers than expected. The DON acknowledged that the medications were available and should have been administered, emphasizing the importance of following physician orders to prevent complications. The facility's policy on medication administration requires that medications be administered as prescribed to ensure compliance with dose guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals were stored in accordance with professional principles, as evidenced by the presence of sticky residue in the bottom drawer of medication cart #3 and around the cap of a bottle of Pro-Stat liquid. During an observation, it was noted that boxes placed on the sticky residue in the drawer adhered to it, and the Pro-Stat liquid bottle was difficult to keep clean due to the residue. An interview with an LVN confirmed the presence of the sticky residue and acknowledged that the medication cart should be kept clean and free from such residue. The facility's policy and procedure on medication storage, dated August 2019, requires medication storage areas to be clean and free of clutter, and mandates the removal of contaminated or deteriorated medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post the most recent survey results conducted by the California Department of Public Health (CDPH) in areas that are prominent and accessible to residents, their representatives, family members, and visitors. During an observation and interview, the Administrator admitted that the survey binder displayed in the hallway contained outdated results from May 2021, rather than the most recent survey conducted in December 2023. The Administrator acknowledged that the latest survey results were kept in her office and not made accessible to the residents and their families, which is a violation of the residents' rights. The facility's policy and procedure, as well as the admission packet, clearly state that residents have the right to examine the results of the most recent survey conducted by federal or state surveyors. These documents emphasize that the survey results and any plan of correction must be available for examination in a place readily accessible to residents. The failure to post the updated survey results hindered the rights of the residents and their families to be informed about the facility's compliance status and past performance history.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary environment for one resident, identified as Resident 20, by not emptying the trash in a timely manner, which led to the production of gnats. Resident 20, who was admitted with diagnoses including hypertension, schizophrenia, and depression, was observed to have moderate cognitive impairment but was independent in dressing, bathing, and eating. During an observation and interview with the Infection Preventionist Nurse, the trash can in Resident 20's room was found overflowing with gnats present, indicating a risk of infection. The facility's policy requires providing a safe, clean, comfortable, and home-like environment, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to transmit the discharge Minimum Data Set (MDS) for a resident within the required 14 days after completion to the Center of Medicare and Medicaid Services (CMS). This deficiency was identified for one of the 22 sampled residents. The resident in question, who had diagnoses including schizophrenia, chronic obstructive pulmonary disease (COPD), and encephalopathy, was discharged to a General Acute Care Hospital on the same day the MDS assessment was dated. However, the MDS assessment was not transmitted until more than 14 days after the Assessment Reference Date (ARD), which was 4/22/2024. During an interview, the Minimum Data Set Nurse (MDSN) confirmed that the MDS assessment was completed and transmitted late, on 5/9/2024, instead of by the deadline of 5/6/2024. The Director of Nursing (DON) acknowledged that the delay in transmitting the MDS discharge assessment could affect facility reimbursement and staffing needs. The facility's policy and procedure on the RAI Process, dated 10/4/2016, requires timely submission of resident assessments to meet state and federal guidelines, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for one of the sampled residents, identified as Resident 40. This resident was admitted with diagnoses including diabetes mellitus, schizophrenia, and end-stage renal disease. The resident's admission record and subsequent assessments indicated a lack of capacity for medical decision-making, yet the Minimum Data Set (MDS) noted intact cognition. Despite these complexities, the required Level II evaluation was not conducted because the resident was reportedly unavailable for the assessment, possibly due to being out of the facility. The Minimum Data Set Nurse (MDSN) acknowledged that the staff should have resubmitted the Level I evaluation to schedule a Level II assessment. The absence of this evaluation meant that the facility did not have the necessary mental health recommendations to ensure appropriate placement and care for the resident. The facility's policy, dated July 2018, assigns the responsibility of updating PASARR evaluations to the MDS Coordinator, highlighting a lapse in following established procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop an individualized, person-centered care plan with measurable objectives, timeframes, and interventions for a resident who experienced significant weight loss. The resident, who had diagnoses including dementia, dysphagia, and severe protein-calorie malnutrition, lost 5.2% of their body weight in one week and 6.9% in one month. Despite these significant changes, the facility did not create a care plan to address the resident's nutritional needs, which was acknowledged by the Dietary Service Supervisor during a review of the resident's clinical records. The Minimum Data Set assessment indicated that the resident was not cognitively intact and required supervision for eating, oral hygiene, and upper body dressing. The facility's policy on Comprehensive Person-Centered Care Planning emphasizes the importance of updating care plans based on assessed needs, yet this was not done for the resident in question. The lack of a care plan for the resident's significant weight loss was identified as a deficiency, with the potential to place the resident at risk for further weight loss due to the absence of nutritional interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently monitor the weight of one resident, identified as Resident 56, which is crucial for managing their health conditions. Resident 56 had a history of Type 2 Diabetes Mellitus, unspecified protein-calorie malnutrition, a pressure ulcer, and anemia. The resident's weight was recorded as 180 pounds on June 14, 2024, and 171 pounds on both July 15 and July 22, 2024. However, there was no subsequent weight recorded after July 22, 2024, despite the resident being on an appetite stimulant, which necessitates regular weight monitoring to assess any significant weight changes. The facility's policy, titled 'Evaluation of Weight Nutritional Status,' mandates that weekly weights should be discontinued only when a resident's weight has been stable for four weeks, with monthly evaluations continuing for all residents. During an interview, RN 1 confirmed that weights should be taken monthly unless otherwise ordered. The failure to adhere to this policy for Resident 56, who was at risk for nutritional problems, meant that the facility staff could not effectively monitor and report significant weight changes to the doctor, potentially delaying necessary interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary vision care services to a resident, identified as Resident 37, who reported missing prescription eyeglasses. Despite the resident's report to the facility staff about the missing eyeglasses two weeks prior, no follow-up action was taken to arrange for an optometry consult. The resident, who has diagnoses including parkinsonism, schizophrenia, and dysphagia, expressed difficulty in seeing print and television screens without the eyeglasses. The resident's last eye care consult was on 9/4/2023, and there was no subsequent follow-up, despite an order for eye health and vision consult being present in the resident's Order Summary Report dated 1/9/2025. Interviews with the Social Service Director (SSD) and the Director of Staff Development (DSD) revealed that the SSD acknowledged the lack of a written report regarding the missing eyeglasses and admitted it was her responsibility to refer the resident to an eye doctor. The facility's policy and procedure for referrals to outside services, which mandates coordination of such referrals by the Director of Social Services, was not followed. The DSD highlighted the risk of not referring the resident to an eye doctor, which could lead to worsening vision and affect the resident's quality of life. The facility's policy on resident rights emphasizes care that promotes quality of life and well-being, which was not upheld in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident 52, had a low bed and bilateral floor mats as per the physician's order, which was intended to enhance safety and prevent falls. Resident 52 was admitted with diagnoses including hypertension, dementia, and cardiomegaly, and was dependent on staff for various activities of daily living. The resident's care plan and fall risk evaluation indicated a risk for falls due to confusion, balance problems, and decreased muscle coordination. Despite these documented needs, an observation revealed that the resident's bed was not in a low position, and there were no floor mats present. During an interview and record review, a Licensed Vocational Nurse confirmed that the resident did not have the required safety measures in place, acknowledging that the resident was not safe and could be injured if a fall occurred. The facility's policies on fall management and resident safety, which emphasize providing a safe environment to minimize fall-related complications, were not adhered to in this instance. This oversight placed Resident 52 at risk for injury, highlighting a deficiency in the facility's adherence to prescribed safety protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly measure and document the arm circumference and external catheter length for a resident with a midline catheter. This oversight was identified for one out of two residents who had a midline catheter, specifically Resident 56. The resident was admitted with conditions including Type 2 Diabetes Mellitus, a pressure ulcer, and a urinary tract infection. Despite the facility's policy requiring documentation of arm circumference and exposed catheter length, there was no record of these measurements in the resident's progress notes or IV administration record from November 22, 2024, to December 20, 2024. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the lack of documentation. The RN acknowledged the importance of assessing and monitoring the midline site for signs of infection, which includes measuring the arm circumference. The DON stated that these measurements should be taken at least weekly and documented to track the progress of the insertion site. However, the absence of such documentation indicated a failure to adhere to the facility's established procedures, potentially missing complications associated with the midline catheter for Resident 56.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident 41, received proper monitoring for oxygen saturation levels as per the physician's order. Resident 41 was admitted with diagnoses including emphysema, schizophrenia, and hypertensive heart disease without heart failure. The physician had ordered oxygen at 2 liters to maintain oxygen saturation at or above 92% after the resident's saturation dropped to 88% on a previous occasion. However, the facility did not consistently monitor the resident's oxygen saturation levels, with gaps in monitoring noted between specific dates. During an observation, Resident 41 was found in bed without wearing oxygen, and a review of the resident's records revealed that oxygen saturation had not been checked for several days. An LVN confirmed that the staff had not been monitoring the resident's oxygen saturation as required, which could have resulted in the resident needing oxygen without receiving it. The facility's policy on obtaining vital signs indicated that vital signs should be taken before initiating treatment when there are conditional parameters, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post updated daily nurse staffing information, which is a requirement to ensure transparency and compliance with state regulations. During an observation and interview with the Director of Staff Development (DSD), it was revealed that the last posted nurse staffing information was dated 12/18/2024, indicating that the information was not current as of 1/7/2025. The DSD, who was new to the position, acknowledged the oversight and stated that the nurse staffing information should include both projected and actual hours worked by licensed nurses and CNAs, as well as the total number of residents in the facility. This information is crucial for determining if the facility meets the staffing hours required by the California Department of Public Health. The facility's policy and procedure, titled 'Nursing Department - Staffing, Scheduling and Posting,' dated 7/2018, mandates that nurse staffing data be posted daily at the beginning of each shift. The DSD emphasized the importance of posting and updating this information to ensure that the facility meets the needs of its residents and complies with state regulations. The failure to post updated staffing information was identified as a violation of resident rights, as it potentially deprived residents and the public of timely access to this critical information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a licensed pharmacist performed a Medication Regimen Review (MRR) for one of the sampled residents, identified as Resident 40, for the month of November 2024. This oversight was discovered during a review of the facility's MRR binder, where it was confirmed by the Registered Nurse Supervisor (RNS) that no MRR had been completed for Resident 40 during that month. The RNS acknowledged the importance of the MRR in identifying potential drug interactions and making necessary recommendations to prevent overmedication. Resident 40 was admitted to the facility with multiple diagnoses, including diabetes mellitus, schizophrenia, and end-stage renal disease. The resident's medical records indicated a lack of capacity for medical decision-making, although the Minimum Data Set (MDS) assessment showed intact cognition. The facility's policy, dated December 2016, mandates a monthly review of each resident's medical chart by a pharmacist, which was not adhered to in this case, putting Resident 40 at risk of drug interactions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents received necessary laboratory tests as ordered by their physicians, which could potentially delay treatment. Resident 6, who was diagnosed with hyperlipidemia, hypernatremia, and vitamin B12 deficiency anemia, was supposed to have monthly Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) tests. However, only a CMP was completed on one occasion, and there was no lab requisition form for the monthly CBC and CMP. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged the importance of monitoring lab results for Resident 6 due to her anemia diagnosis. Similarly, Resident 40, who had diagnoses including diabetes mellitus, schizophrenia, and end-stage renal disease, did not have a CBC and Basic Metabolic Panel (BMP) completed as ordered by the physician. The physician had ordered these tests to monitor the resident's kidney function, but the lab work was not completed, leaving the resident's health status unmonitored. This was confirmed during an interview with another LVN, who noted the absence of lab results and the inability to follow up and provide appropriate care. The facility's policy and procedure on laboratory services emphasized the need for timely and accurate lab services, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three out of four dumpsters had their lids closed, which was observed during a concurrent observation and interview with the Dietary Services Supervisor (DSS) on January 7, 2025, at 8:20 a.m. The DSS acknowledged that the dumpsters should be closed to prevent attracting animals. This practice was in violation of the 2022 U.S. Food and Drug Administration Food Code, specifically code number 5-501.116, which requires outside receptacles to have tight-fitting lids or covers to prevent the scattering of garbage or refuse by birds, the breeding of flies, or the entry of rodents. This deficiency had the potential to attract rodents to the trash area.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the average daily census in its Facility Assessment, which is a critical process for evaluating the resident population and identifying the necessary resources to provide care and services. During an interview and record review, the Administrator acknowledged that the Facility Assessment, last updated on 7/22/2024 and revised on 11/15/2024, was incomplete and did not include the average daily census of residents. This omission was recognized as a deficiency by the Administrator, who admitted responsibility for updating the Facility Assessment and acknowledged the importance of including the average daily census to adequately plan for staffing needs and resource allocation. The facility's policy and procedure, dated 4/15/2021, required the Administrator to review and update the Facility Assessment annually and as needed when there are changes that necessitate substantial modifications. Additionally, guidance from the Centers for Medicare and Medicaid Services (CMS), dated 6/18/2024, emphasized that the assessment of the resident population should help identify additional needs such as physical space, equipment, and other resources required for resident care. The failure to include the average daily census in the Facility Assessment had the potential to delay care and treatment services due to inadequate planning for staffing and resource allocation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the pain management consult report for a resident was accessible and filed in their medical records. This deficiency was identified during a review of the resident's medical chart, which revealed that consultation notes and progress notes from Dr. O'Malley were missing. The Medical Records Director (MRD) confirmed that the previous MRD had resigned, and Dr. O'Malley had been emailing the notes to her email address, with no other department members receiving them. This resulted in an incomplete medical chart, potentially hindering other doctors or staff from reviewing the necessary information. Additionally, the facility failed to indicate the correct discharge disposition for another resident. The resident's admission summary and social services notes confirmed plans for discharge home, and the discharge summary indicated the resident was discharged home with instructions and medications. However, a review of the Minimum Data Set (MDS) revealed that the resident was incorrectly documented as discharged to the hospital. The MDS Nurse acknowledged the error, which could lead to confusion regarding the resident's discharge status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with Alzheimer's Disease and other cognitive impairments understood the legal documents, including a binding arbitration agreement, that she signed during her admission. The resident, who had a diagnosis of Alzheimer's Disease, dementia, and schizoaffective disorder, was found to have fluctuating capacity to understand and make decisions. Despite this, the facility allowed her to sign the arbitration agreement electronically without involving her responsible party, who was designated to make decisions on her behalf due to her cognitive impairments. Interviews and record reviews revealed that the facility staff did not contact the resident's responsible party to explain the arbitration agreement, as required by the facility's policies. The Admission Coordinator acknowledged that the resident should not have been asked to sign the agreement due to her dementia diagnosis. The Social Service Consultant confirmed that the resident lacked the capacity to make sound decisions and that the signed arbitration agreement was not valid. The facility's policies indicated that if a resident lacks capacity, a surrogate decision maker should provide informed consent, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms for 31 out of 34 rooms. During a facility tour, it was observed that residents could move in and out of their rooms, and there was space for beds, side tables, and resident care equipment. However, the Maintenance Supervisor confirmed that the rooms were less than the required size. A waiver request was submitted by the Administrator, indicating that the waiver would not adversely affect the residents' health and safety. The rooms in question provided less than the required 240 square feet for three residents, with measurements ranging from 221.6 to 226.6 square feet.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse prevention policy and procedure when a Certified Nursing Assistant (CNA) did not immediately report a verbal altercation between two residents, which escalated into a physical assault. The incident involved a resident with severe cognitive impairment and physical limitations, who was unable to move independently, and another resident with moderate cognitive impairment and a history of mental health disorders. The altercation began with a verbal threat over a television remote and escalated to physical violence, resulting in the first resident being struck in the face multiple times. The CNA, who was not assigned to the room where the incident occurred, overheard the initial verbal altercation but did not report it immediately. Despite witnessing the physical assault, the CNA only intervened verbally and did not report the incident to the supervising nurse until after a third altercation was overheard. This delay in reporting allowed the aggressive resident to continue the assault, causing the victim pain and fear of further abuse. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that all staff members are mandated reporters and are required to report any incidents of abuse immediately, regardless of their assigned duties. The facility's policies clearly state that abuse, including verbal and physical, must be reported promptly to ensure resident safety. The failure to adhere to these policies resulted in a delay in intervention and further harm to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Certified Nursing Assistant (CNA) had the appropriate competencies and skills required for reporting resident abuse immediately after witnessing a resident-to-resident altercation. This incident involved two residents, Resident 9 and Resident 10, where Resident 10 was observed hitting Resident 9. Despite witnessing the abuse, CNA 1 did not report the incident immediately, which placed Resident 9 at risk for continued abuse and potential harm. Resident 9, who was admitted with severe cognitive impairment and physical disabilities such as hemiplegia and hemiparesis, was dependent on staff for mobility. Resident 10, on the other hand, had moderate cognitive impairment and mental health diagnoses, including anxiety disorder and schizoaffective disorder, and was capable of independent mobility. The altercation occurred when CNA 1 overheard verbal disputes and later witnessed Resident 10 physically assaulting Resident 9. Despite this, CNA 1 did not report the incident immediately, citing that Room A was not assigned to her care. Interviews with the Registered Nurse (RN) and the Director of Staff Development (DSD) confirmed that all staff, regardless of assignment, are responsible for reporting abuse immediately to ensure resident safety. CNA 1 had completed abuse training and was aware of the requirement to report abuse immediately, as indicated in her employee file. The facility's policies also mandated prompt reporting of abuse and resident-to-resident altercations to prevent further harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse when another resident punched them in the face. This incident occurred because the facility did not adequately monitor the whereabouts of the resident who was punched, despite being aware of their tendency to wander. The resident who was punched had a history of schizophrenia, bipolar disorder, and dementia, and required supervision for walking, dressing, and personal hygiene. The facility's care plan for this resident included interventions to distract them from wandering, but these measures were not effectively implemented. The resident who committed the physical abuse had a history of schizoaffective disorder, anxiety, and depression, with fluctuating capacity to understand and make decisions. Their care plan noted behavior problems related to unpredictable mood changes and included interventions for frequent visual monitoring to ensure the safety of themselves and others. However, the facility did not adequately monitor this resident, leading to the incident where they punched the other resident after being startled by their presence in their room. Interviews with staff, including the DON and RN, revealed that both residents were known to have behavioral issues that required close monitoring. The staff acknowledged that the resident who wandered into the other resident's room could have been seriously hurt, and the resident who committed the abuse had a history of delusional thoughts and aggressive behavior. The facility's policies on wandering, elopement, and abuse prevention were not effectively followed, contributing to the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a care plan was developed for a resident regarding food brought in from outside the facility. During an observation, it was noted that the resident had two bags of opened chips and a loaf of bread with an expiration date at their bedside. The resident, who was diagnosed with major depressive disorder, diabetes mellitus, and schizophrenia, was on a therapeutic diet and required staff assistance for eating. Despite these needs, there was no care plan addressing the management of outside food, which could lead to potential adverse reactions or pest infestations. Interviews with the facility's staff, including a registered nurse and the director of nursing, revealed that there was a lack of education provided to the resident about the risks associated with outside food. The staff acknowledged the importance of having a care plan that included education, dietitian, and physician recommendations to prevent negative outcomes. The facility's policy on comprehensive person-centered care planning emphasized the need for a baseline care plan that reflects the resident's goals and includes necessary interventions, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food items at a resident's bedside were properly labeled and dated, which could potentially lead to foodborne illness. During an observation, two bags of opened potato chips and a loaf of bread were found on the resident's overhead table, and the resident was unable to recall how long the items had been there. The resident, who was on a therapeutic diet and required staff assistance for eating, had been escorted by activities staff to purchase food items, which were supposed to be labeled with the resident's name, room number, and date. Interviews with the Activities Director and the Director of Nursing (DON) revealed that the responsibility for labeling and dating the resident's food items fell to the activities staff. The DON emphasized the importance of dating food items to prevent the consumption of expired food, which could cause illness. A review of the facility's policy on food storage and handling confirmed that all food items should be correctly labeled and dated to avoid foodborne illnesses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident by not correctly coding the medication Depakote as an anticonvulsant in the MDS assessment under Section N (N0415-High-Risk Drug Classes). This error was identified during a review of the resident's records, which showed that the resident had an active order for Depakote, a medication used for mood disorders, but it was not marked as an anticonvulsant in the MDS. The MDS Nurse acknowledged the mistake, stating that the coding should be based on the pharmacological classification of the medication, not the reason for its prescription. The inaccurate MDS assessment resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS). The resident involved had a history of schizoaffective disorder, epilepsy, and depression, and was noted to have moderately impaired cognitive skills for daily decision-making. The facility's policy and procedure on the RAI Process emphasized the importance of accurate resident assessments to meet state and federal guidelines. Interviews with the Administrator and the Director of Nursing revealed differing views on the impact of the inaccurate MDS assessment, with the Administrator stating it would not compromise resident care, while the Director of Nursing acknowledged it could affect resident care and CMS payments.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect three residents from physical abuse, resulting in multiple altercations involving Resident 2. Resident 2, who has a cognitive communication deficit and schizophrenia, was involved in several incidents where he either instigated or was the victim of physical aggression. On one occasion, Resident 7 punched Resident 2 after he attempted to steal her coffee. Resident 2's behavior of taking other residents' belongings was known to the staff, yet his care plan was not updated to address this issue. Resident 2's aggressive behavior continued, as evidenced by an incident where he threw hot coffee at Resident 1 and kicked him, resulting in a thumb injury for Resident 1. Despite being placed on one-to-one supervision following this incident, Resident 2 was involved in another altercation with Resident 6, where he kicked her in the leg, causing severe pain. Resident 6 expressed feeling unsafe and frustrated due to Resident 2's repeated thefts and the facility's lack of intervention. The facility's policy on abuse prevention and management was not effectively implemented, as staff failed to separate residents involved in altercations and did not revise Resident 2's care plan to mitigate his behavior. Interviews with staff and residents revealed a lack of awareness and action regarding the ongoing issues with Resident 2, leading to a planned confrontation by other residents who felt their concerns were not being addressed. The Director of Nursing acknowledged the residents' frustrations and the facility's failure to provide a safe environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and revise the care plan interventions for a resident with a history of stealing food and drinks from other residents. Despite the care plan being initiated to address this behavior, there were no documented revisions or effective interventions implemented. The resident's behavior continued, leading to multiple incidents of theft and altercations with other residents. The resident in question was admitted with cognitive communication deficits and schizophrenia, which contributed to his behavior of stealing. The care plan, dated shortly after his admission, included goals to prevent further episodes and required staff to monitor and document the behavior. However, staff failed to document the occurrences or take necessary actions to protect other residents, resulting in continued thefts and psychosocial distress among the affected residents. Interviews with staff and residents revealed that the resident's behavior was well-known, yet no effective measures were taken to address it. The Director of Nursing acknowledged the lack of revisions to the care plan and the failure to prevent the resident from stealing. This inaction led to physical altercations between the resident and others, as well as a general sense of insecurity and frustration among the residents whose belongings were repeatedly stolen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that landing mats were placed on both sides of the bed for one of the residents, increasing the potential for avoidable physical harm due to possible injury from a repeat fall. The resident, who was admitted with diagnoses of schizophrenia and anxiety disorder, had impaired cognition and required assistance for mobility. The resident's physician orders, dated several months prior, specified the need for landing mats on both sides of the bed, but these were not present during observations. During observations, it was noted that the resident was at risk for falls, and the absence of landing mats was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The LVN was unaware of the resident's fall risk and the requirement for landing mats, while the DON acknowledged the lack of a care plan documenting the need for these mats. The facility's policy required documentation of fall interventions, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy and procedure regarding discharge planning by not involving the Interdisciplinary Team (IDT) for two residents. Resident 1, who had a history of cerebral infarction, psychoactive substance abuse-induced psychotic disorder, insomnia, strokes, and schizophrenia, was discharged without an IDT meeting. The Social Service Assistant (SSA) was not informed of the discharge plan or order until after the discharge occurred, resulting in no IDT meeting being conducted. The Director of Nursing (DON) confirmed that there were no progress notes indicating an IDT meeting for Resident 1's discharge planning, which is required for resident safety and to ensure adequate care post-discharge. Similarly, Resident 2, diagnosed with schizoaffective disorder, autistic disorder, and anxiety disorder, was discharged without an IDT meeting. The resident had a designated responsible party for medical decisions, but this party was not notified of the discharge plan. The SSA was unaware of the discharge plan or order until after the discharge, leading to the absence of an IDT meeting. The DON confirmed that no IDT meeting was documented for Resident 2's discharge planning. The facility's policy requires that social services communicate with residents and their families and involve them in care planning meetings, and that each IDT member participates in and documents the discharge summary and post-discharge plan of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a written notice of discharge and the right to appeal to the representative of a resident prior to the resident's discharge to an assisted living facility. The resident, who had diagnoses including schizoaffective disorder, autistic disorder, and anxiety disorder, was unable to make medical decisions and had a designated responsible party. Despite this, the resident's representative was not informed of the discharge in writing or by phone, nor were they informed of their right to appeal the discharge decision. Interviews and record reviews revealed that the Social Service Assistant and Licensed Vocational Nurse were not aware of the discharge plan, and the Notice of Proposed Transfer and Discharge did not include a date or signature indicating that the resident or their representative had been notified. The Director of Nursing confirmed that the facility's policy and procedure required written notification and acknowledgment from the resident's representative prior to discharge, which was not followed. The Administrator also admitted to not notifying the resident's representative about the discharge plan or order.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to report an allegation of abuse involving a resident in a timely manner, as required by their operational manual and state regulations. On the night shift, a resident was allegedly punched by a Certified Nurse Assistant (CNA), resulting in a bruise on the resident's left cheek near the eye. This incident was reported by the resident's caretaker to the Social Services Assistant (SSA) the following day. However, the SSA did not report the incident to the Administrator, the California Department of Public Health (CDPH), or local law enforcement within the required two-hour timeframe. The resident involved in the incident had been admitted to the facility with diagnoses including a Stage 4 pressure ulcer and a urinary tract infection. The resident was dependent on assistance for activities of daily living and had a documented inability to understand and make decisions. Despite these vulnerabilities, the facility's records did not reflect any documentation of the incident or the resident's condition change following the alleged abuse. Interviews conducted during the investigation revealed that the SSA acknowledged the failure to report the incident promptly, which delayed the investigation by CDPH and potentially placed the resident at risk for further abuse. The facility's operational manual clearly outlined the procedures for reporting such incidents, including immediate notification to the Administrator and submission of a written report to CDPH within 24 hours. The SSA's failure to adhere to these protocols constituted a significant deficiency in the facility's handling of abuse allegations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate an allegation of abuse involving a resident who was reportedly punched by a Certified Nurse Assistant (CNA) during the night shift. The incident occurred on 5/28/2024, and the resident, who had a Stage 4 pressure ulcer and a urinary tract infection, was dependent on assistance for activities of daily living. The resident was able to communicate and reported the abuse to a caretaker, who then informed the Social Service Assistant (SSA) on 5/29/2024. However, the SSA did not report the incident to the Administrator as required by the facility's policy. The facility's Operational Manual mandates immediate reporting and investigation of abuse allegations, but this protocol was not followed. The SSA confirmed the report from the caretaker but failed to notify the Administrator, resulting in a lack of documentation and investigation into the incident. The Director of Nursing was also unaware of the incident until informed by a family member. The facility's policy requires immediate removal and suspension of the suspected perpetrator, but there is no indication that these steps were taken promptly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's indwelling catheter was secured with an anchoring device, which is necessary to prevent accidental pulling, dislodgement, and potential injury. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), who confirmed that the catheter was not anchored. The facility's policy and procedure for catheter care, which aligns with CDC guidelines, mandates that catheters be anchored to prevent urinary tract infections and ensure they do not touch the floor. The resident involved had a history of a Stage 4 pressure ulcer and a urinary tract infection, and was dependent on assistance for activities of daily living. The Minimum Data Set indicated that the resident had an indwelling catheter and was always incontinent of bowel. Despite these needs, the catheter was not secured, as verified by the CNA during a subsequent observation. The LVN acknowledged the risk of serious injury and hospitalization due to the unsecured catheter, highlighting a lapse in adherence to the facility's catheter care policy.