Veterans Home Of California - Yountville - Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Yountville, California.
- Location
- 100 California Drive, Yountville, California 94599
- CMS Provider Number
- 555095
- Inspections on file
- 40
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Veterans Home Of California - Yountville - Snf during CMS and state inspections, most recent first.
The facility failed to provide food that was palatable and at the correct temperature, as multiple residents reported cold and flavorless meals. Observations revealed that rethermalization carts were not maintaining proper food temperatures, leading to inadequately heated meals. The Food Service Supervisor confirmed the issues with flavor and texture, noting bland and fibrous vegetables and dry chicken.
The facility failed to ensure food safety and sanitation standards were met, as hot and cold food temperatures were not consistently monitored, leading to potential foodborne illness risks. Air vents in the kitchen were unclean, and staff did not adhere to facial hair covering policies. Additionally, food service equipment was in poor condition, with cracked trays and an unclean can opener, further increasing contamination risks.
The facility failed to accurately document and manage controlled substances for several residents, leading to discrepancies between the MAR and CDR. Inconsistent processes for handling narcotic medications designated for destruction were identified, and the facility did not follow its policy for managing medications during residents' out-on-pass status. These deficiencies were confirmed by the DON and nursing staff.
The facility failed to remove expired medications and properly label opened multi-dose biologicals. Expired medications, including ointments, antiseptics, and supplements, were found in the medication storage room. Additionally, a vial of Tubersol was found without an open date label, contrary to manufacturer instructions. Staff confirmed these deficiencies, acknowledging the need for proper labeling and removal of expired items.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene and PPE protocols. Cleaning procedures were not followed, and inappropriate solutions were used, risking cross-contamination. Enhanced Barrier Precautions were not implemented for residents with indwelling devices, and sterile technique was compromised during a nephrostomy tube procedure.
A resident with Alzheimer's and Vascular Dementia was improperly restrained in bed with all four bedrails up and a bedside table over their body, restricting movement. Facility staff were unaware of the restraint use, and no restraint order was in place. The facility's policies prohibited such use of bedrails, yet they were not followed.
A resident with multiple diagnoses did not have their medication administration documented by an RN, who admitted to administering the medications but failing to initial the MAR. This oversight was against facility policy, which requires documentation at the time of administration, and placed the resident at risk for medication errors.
The facility failed to maintain a walk-in freezer in the Main Kitchen, resulting in significant ice build-up on the ceiling and food boxes. The Food Manager was unaware of the issue, and the Dietary Director confirmed that freezers should be ice-free. Due to staff shortages, inspections were less frequent, contrary to the facility's policy of maintaining equipment in good working order.
A resident with cognitive impairment and a history of falls was found deceased outside a facility's basement exit door after being reported missing. The search was inadequately conducted, with staff failing to check key areas and assuming the Office of Public Safety would handle the exterior search. The facility lacked clear procedures and training for missing resident situations, contributing to the tragic outcome.
A resident experienced a choking episode and subsequent respiratory distress, with oxygen saturation levels in the 70s. The facility failed to promptly notify the physician, as required by their policy, leading to a delay in care. Attempts to contact the doctor on-call were unsuccessful, and there was no documentation of these attempts. The resident was eventually transferred to the hospital, where they died of cardiac arrest.
A facility failed to ensure the Doctor on Call responded promptly to a resident's change in condition. An LVN attempted to contact the doctor twice without success and was advised by a supervisor to call 911. The doctor later admitted to missing the calls due to a phone ringer issue. The facility's policy required a response within 10-15 minutes, which was not met, leading to the resident being sent to the hospital without physician guidance.
A resident with Stage IV Colon Cancer experienced a choking episode and respiratory distress, but the LTC facility failed to document vital signs, oxygen application, and communication with medical personnel. Staff interviews revealed inconsistencies and gaps in documentation, and facility policies for documentation and changes in condition were not followed, resulting in incomplete and inaccurate medical records.
A resident with multiple diagnoses, including Schizoaffective Disorder and PTSD, was unaccounted for two days after signing out of the unit without specifying a destination. The night shift nurse did not report the absence, and the facility's policy for missing residents was not followed, resulting in the resident missing scheduled medications. Interviews revealed a lack of communication and adherence to procedures among staff.
The facility failed to adhere to professional standards for food service safety, with live roaches found in multiple kitchen areas, build-up of food crumbs and grime on floors, improper documentation of food cooling processes, and nursing staff handling ready-to-eat food with bare hands. These deficiencies increased the risk of food contamination and foodborne illness for residents.
The facility failed to maintain an effective pest control program, resulting in a persistent roach infestation in the [NAME] staging kitchen. Observations revealed live roaches, unsanitary conditions, and a propped-open door allowing pests to enter. The Pest Technician confirmed the presence of German Cockroaches, and a facility work order indicated an increase in sightings. This posed a risk of disease transmission to 197 medically compromised residents.
The facility failed to ensure that call lights were within reach in restrooms, as observed with several residents. A CNA confirmed the improper placement of the call-light, and an RN stated that staff direct residents to use the call-light for assistance. The facility's policy requiring readily accessible call-lights was not followed.
The facility failed to maintain a clean environment by not cleaning a visibly soiled wheelchair and not cleaning resident lift equipment after use, contrary to their policies.
The facility failed to conduct a Significant Change in Status Assessment (SCSA) within 14 days for a resident after the emergence of a new unstageable pressure injury and unplanned weight loss. Staff interviews revealed a lack of communication and adherence to facility policies regarding IDT meetings and MDS notifications.
The facility failed to update the care plan for a resident with cognitive decline and muscle weakness, inaccurately stating the use of a four-wheel walker instead of a wheelchair. This discrepancy was confirmed by a supervising nurse and observed multiple times, leading to concerns about the resident's rehabilitation needs.
The facility failed to revise the care plan for a resident when the resident's wound care orders were changed. The resident had bilateral heel wounds from ischemia and peripheral arterial disease. The care plan still indicated outdated treatment instructions, and the MDS Coordinator confirmed that it should have been updated.
A facility failed to provide community activities for a resident, preventing meaningful community connection and quality of life improvement. The resident expressed dissatisfaction with the reduced activities and outings, citing transportation issues and COVID-19 concerns as barriers. The care plan and activity log confirmed no community outings in the past three months.
The facility failed to ensure a timely audiology assessment and replacement of a hearing aid for a resident with Age-Related Cognitive Decline and Sensorineural Hearing Loss. Despite multiple requests and a referral inputted five months prior, no appointment was scheduled, resulting in the resident not receiving the necessary care.
The facility failed to provide timely PT per physician's order for a resident, resulting in a delay of care for over a month. The resident, who had COVID a month ago, was observed in a wheelchair and required assistance for ambulation. Despite a care plan for range of motion exercises and ambulation with a 4WW, the first PT assessment did not occur until over a month later, contributing to the resident's prolonged use of a wheelchair and decline in mobility.
The facility failed to ensure a discontinued Novolin R Insulin Sliding Scale was not carried over to the current physician's order for a resident. The Nurse Practitioner confirmed that the undated sliding scale was discontinued previously and should not have been included in the current order. This oversight had the potential for medication administration error.
The facility failed to ensure proper storage of medications when a resident's Voltaren was found without a cap in a container with other residents' medications. The MDS Coordinator confirmed that the medication should have a cap to maintain its integrity. The facility's policy indicated that drug containers without secure closures should not be used.
The facility failed to maintain Transmission Based Precautions for two residents. An Xray Technician did not wear the required PPE while providing care for a resident on droplet isolation precautions. Additionally, another resident was exposed to contaminated PPE due to the placement of a disposal bin obstructing the path to his bed, leading him to touch the used PPE without performing hand hygiene.
The facility failed to maintain a clean and sanitary environment. Three windows on Unit 1D were visibly soiled and had spider webs, and a plastic urinal in a resident's room was found unlabeled and undated. These conditions were confirmed by staff and violated the facility's cleaning policies.
The facility failed to ensure timely cardiology and neurosurgery follow-ups for a resident after multiple falls and did not regularly change another resident's visibly soiled compression stockings, leading to potential adverse effects on their medical conditions.
A facility failed to update a resident's Care Plan with Occupational Therapy recommendations for Stand By Assist (SBA) to Contact Guard Assist (CGA) and line-of-sight supervision, potentially compromising the resident's safety and care.
A resident did not receive a timely OT evaluation, and the OT recommendations for stand-by assistance and line-of-sight supervision were not incorporated into the care plan. This led to several potentially preventable falls.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable in terms of temperature, flavor, and texture. During the initial screening, multiple residents reported that the food was often cold and flavorless. Observations and document reviews revealed that the rethermalization carts used to reheat and maintain food temperatures were not functioning properly, resulting in food being served at inadequate temperatures. Specifically, a test-tray observation showed that pureed chicken and mashed potatoes were served at temperatures below the desired level, making them barely warm. Additionally, the vegetables served were bland and had an unappealing texture, with some being described as crunchy and fibrous. The Food Service Supervisor confirmed the issues with the food's flavor and texture, noting that the vegetables lacked flavor and the chicken was dry. The facility's failure to maintain proper food temperatures and ensure palatability had the potential to lead to decreased food intake among residents, which could result in food-related medical complications. The report references the position of the American Dietetic Association, which emphasizes the importance of a palatable diet for maintaining the nutritional status and quality of life of older adults in long-term care facilities.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. The facility did not have a reliable system to ensure that all hot food was reheated to a minimum of 165 degrees Fahrenheit and that all cold food was held at or below 41 degrees Fahrenheit. During observations, it was noted that food temperatures on several trays were below the required standards, and the staff only monitored temperatures on one test tray per meal, which did not accurately reflect the temperatures of all trays. This inconsistency in monitoring and reheating food posed a risk of foodborne illness to the residents. Additionally, the facility's kitchen environment was not maintained in a clean and sanitary condition. Three air vents in the dish room and food production area were observed to have a black, fuzzy substance resembling dust, indicating a lack of regular cleaning. The facility's housekeeping and plant operations staff had unclear responsibilities and schedules for cleaning these vents, leading to their unclean state. Furthermore, supervisory staff in the kitchen were observed not wearing appropriate facial hair coverings, which is a violation of the facility's policy and could lead to contamination of food. The condition of the equipment used in food service was also found to be substandard. Trays used for food service were cracked, chipped, and had a buildup of worn and frayed tape, which is against the federal food code requirements for multi-use food-contact surfaces. An industrial can opener was found to be unclean, with visible residue on the blade, indicating it was not cleaned after each use as required. These equipment deficiencies further increased the risk of cross-contamination and foodborne illness for the residents.
Controlled Substance Documentation and Management Deficiencies
Penalty
Summary
The facility failed to ensure accurate accounting and documentation of controlled substance medications for several residents, leading to discrepancies between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). For instance, Resident 75's lorazepam administration was not documented on the CDR, and Resident 81's oxycodone doses were removed from the medication cart but not recorded on the MAR. Similarly, Resident 128's oxycodone administration was not documented on the CDR, and Resident 16's oxycodone doses had discrepancies between the MAR and CDR. These documentation lapses were confirmed by the Director of Nursing (DON) and Nursing Supervisor 2 (NS 2), who acknowledged the discrepancies and the expectation for nursing staff to document controlled medication administration accurately. The facility also failed to establish a reliable system to prevent the diversion of narcotic medications designated for destruction. Interviews with various nursing staff revealed inconsistencies in the process of handling medications that required destruction. Some staff reported storing these medications in a locked compartment in the medication cart, while others described different methods of destruction, such as crushing pills and using a designated waste receptacle. The Registered Nurse Quality Assurance (RN 7) outlined a process for weekly destruction with a pharmacist, but discrepancies in the handling and counting of these medications were evident, as some staff did not include them in shift-to-shift narcotic counts. Additionally, the facility did not adhere to its policy for managing resident medications during out-on-pass (OOP) status. Resident 81's medication release form lacked documentation of the quantity of medication returned upon the resident's return to the facility. Nursing staff failed to record when the last dose of oxycodone was taken by the resident while OOP, which is crucial for determining the timing of the next dose. The DON and NS 2 confirmed these lapses, highlighting the need for accurate reconciliation of medications upon a resident's return from OOP status.
Expired Medications and Improper Labeling of Biologicals
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use and that opened multi-dose biologicals were properly dated. During an inspection of the medication storage room, several expired medications, including Desitin Max Strength, hydrogen peroxide, terbinafine cream, aspirin, and supplements, were found. Nursing Supervisor 1 confirmed these medications were expired and should have been removed. Additionally, a bottle of magnesium tablets was found without an expiration date on a medication cart, and RN 2 acknowledged that nursing staff were expected to label such medications with expiration dates after consulting the pharmacy. Furthermore, an inspection of the medication storage room refrigerator revealed an opened vial of Tubersol without an open date label. RN 3 confirmed that the vial should have been labeled with the date it was opened, as the manufacturer's instructions indicated it should be discarded 30 days after being punctured. The Director of Nursing confirmed that expired medications should not be available for resident use and that multi-dose vials should be labeled with the date opened and expiration date as per the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to hand hygiene and personal protective equipment (PPE) protocols. Contract Staff 1, a Certified Nursing Assistant, and a Custodian Worker were observed not performing hand hygiene or using PPE in accordance with the facility's policy and nationally recognized guidelines. For instance, Contract Staff 1 handled soiled linen without gloves and did not perform hand hygiene after exiting a resident's room. Similarly, a Certified Nursing Assistant did not wear a gown or gloves while providing care to a resident with Enhanced Barrier Precautions due to a wound infection. Additionally, the facility's cleaning procedures were not followed correctly, as observed with a Custodian Worker who did not change gloves or perform hand hygiene between cleaning tasks in different resident rooms. The cleaning solutions used were not appropriate for disinfection, and the worker was unaware of the dwell time required for the disinfectants to be effective. This lack of adherence to proper cleaning protocols placed residents at risk for cross-contamination and infection. The facility also failed to implement Enhanced Barrier Precautions for residents with indwelling medical devices, such as urinary catheters and gastrostomy tubes. For example, a resident with an indwelling urinary catheter did not have the necessary signage or PPE cart outside their room, and staff were not wearing the required PPE during care. Similarly, staff did not wear gowns while administering tube feedings to residents with gastrostomy tubes, despite signage indicating the need for Enhanced Barrier Precautions. Furthermore, sterile technique was not used when flushing a nephrostomy tube for a resident, as non-sterile supplies were handled with sterile gloves, compromising the sterile field and increasing the risk of infection.
Improper Use of Bedrails as Restraints for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 31, was free from physical restraints. During observations, it was noted that Resident 31's bed was positioned against the wall with all four bedrails in the upright position, and a bedside table was placed over the resident's body. This setup restricted the resident's ability to exit the bed voluntarily. The resident, who had diagnoses of Alzheimer's Disease and Vascular Dementia, was not able to communicate effectively, which further complicated the situation. Interviews with facility staff revealed a lack of awareness and communication regarding the use of bedrails as restraints. The designated person responsible for Resident 31's healthcare was not informed about the use of bedrails, and the registered nurse acknowledged that the bedrails should not have been in the upright position. The nurse supervisor confirmed that the facility's policy did not permit the use of four bedrails and that there was no restraint order in place for Resident 31. Additionally, the certified nursing assistant responsible for 30-minute safety checks did not notice the improper use of bedrails during his rounds. A review of Resident 31's records, including the Minimum Data Set, Safety Rounds monitoring log, and Behavior Monitoring Log, indicated no justification for the use of restraints. The facility's policies on bedside rails and physical restraints clearly stated that residents should be free from restraints unless required for medical treatment, and the use of bedrails to prevent voluntary movement was prohibited. Despite these policies, the facility failed to adhere to them, resulting in the improper restraint of Resident 31.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, identified as Resident 57. During a review of the resident's Medication Administration Record (MAR) for March, it was found that the signature boxes for Atorvastatin 80 mg and Isosorbide Mononitrate 30 mg, scheduled for administration at 6 p.m. on March 3rd, were left blank. This lack of documentation meant that it could not be confirmed whether the medications were administered or refused by the resident. The facility's policy requires that nurses initial the MAR at the time of medication administration or circle the boxes if the medication is refused, which was not followed in this instance. Resident 57 had several active diagnoses, including anemia, hypertension, diabetes mellitus, and hyperlipidemia, which necessitated the administration of these medications. RN 6, who was responsible for the PM shift on the day in question, admitted to administering the medications but forgetting to document it in the MAR. This omission was against the facility's policy and placed the resident at risk for a medication dosing error if not identified by the night shift. The facility's policy emphasizes the importance of the 'Right Documentation' as part of the six rights of medication administration, which was not adhered to in this case.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to maintain a walk-in freezer in the Main Kitchen, leading to a significant ice build-up on the ceiling and on boxes of food. During an observation, the ice was measured to be more than 24 inches long, 18 inches wide, and 2 inches thick. The Food Manager was unaware of the ice build-up, and the Dietary Director confirmed that freezers should be free of ice. The Direct Construction Supervisor mentioned that due to a staff shortage, inspections of the freezer were less frequent, occurring about every month instead of every other week. The facility's policy stated that equipment should be maintained in good working order, which was not adhered to in this instance.
Resident Found Deceased Due to Inadequate Search and Unsecured Exit
Penalty
Summary
The facility failed to provide a safe environment for its residents, resulting in the death of a resident who was found outside the facility's basement exit door. The resident, who had a history of falls, cognitive impairment, and other risk factors, was identified as missing when he did not return to his unit. Despite a search being initiated, the resident was not found until later that night by the California Highway Patrol, who discovered him deceased outside the building. The search for the missing resident was inadequately conducted, as key areas were overlooked. Certified Nursing Assistant 1 admitted to not checking the exit door near the smoking area, which was known to be unlocked and accessible, due to an oversight. Registered Nurse 1 and other staff members assumed that the Office of Public Safety would handle the exterior search, leading to a lack of coordination and communication between departments. The facility's policy on missing residents required a search of the immediate outside perimeter, which was not thoroughly executed. Interviews with staff revealed a lack of clear procedures and training for handling missing resident situations. The Office of Public Safety officer expressed frustration over the absence of a detailed standard operating procedure, relying instead on a nursing policy that was insufficient for their needs. The Chief Health and Safety Officer acknowledged that the exit area did not meet safety regulations and was not considered a risk prior to the incident. The facility's failure to secure the exit door and conduct a comprehensive search contributed to the tragic outcome.
Failure to Notify Physician of Resident's Respiratory Distress
Penalty
Summary
The facility failed to immediately notify the physician of a significant change in a resident's breathing status, which resulted in a delay of care. The resident experienced a choking episode during dinner and later showed signs of respiratory distress with oxygen saturation levels in the 70s. Despite the severity of the situation, the facility did not promptly contact the physician, which is a requirement according to their policy and procedure for emergent situations. The facility's policy mandates that in emergent situations, such as significant changes in vital signs or respiratory symptoms, the licensed nurse must notify the supervising registered nurse and the primary care physician or doctor on-call. However, the interdisciplinary progress notes indicated that the physician was not notified of the resident's unstable vital signs after the choking episode. Attempts to contact the doctor on-call were unsuccessful, and there was no documentation of these attempts in the resident's medical record. Interviews with the staff revealed that there was a lack of immediate action to notify the physician. One licensed vocational nurse admitted to not attempting to notify the doctor, while another stated that they tried to call but did not document the attempts. The doctor on-call confirmed that they missed two calls from the facility and were not aware of the resident's condition until hours later. The delay in communication and failure to follow the facility's policy contributed to the resident's transfer to the hospital, where they later died of cardiac arrest.
Failure to Promptly Respond to Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that the Doctor on Call (DOC) responded promptly to a change in condition for a resident. On the night in question, a Licensed Vocational Nurse (LVN) attempted to contact the DOC twice after noticing a change in the resident's condition, but received no response. The LVN then informed the supervisor, who advised calling 911. The DOC later admitted to missing the calls due to inadvertently turning off the phone ringer. The facility's policy required the on-call doctor to respond within 10-15 minutes, which was not met, resulting in the resident being sent to the hospital without the guidance of a physician.
Incomplete Documentation of Resident's Medical Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a change in medical condition. The resident, who had a history of Stage IV Colon Cancer and was a DNR/DNI, experienced a choking episode and subsequent respiratory distress. Despite the severity of the situation, there was a lack of proper documentation regarding the resident's vital signs, the application of oxygen, and the communication with medical personnel. Interviews with staff revealed inconsistencies and gaps in the documentation process. Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) involved in the resident's care did not document vital signs or the initiation of oxygen therapy. Additionally, there was confusion about who applied the oxygen and when the supervising registered nurse and doctor on call were notified. The lack of a designated scribe and reliance on verbal communication contributed to the incomplete records. The facility's policies and procedures for documentation and changes in condition were not followed. The documentation of attempts to notify the doctor on call and the details of the resident's condition were missing or unclear. This failure to adhere to established protocols resulted in incomplete and inaccurate medical records, which did not reflect the resident's condition or the interventions provided during the critical period leading up to the resident's transfer to the emergency department.
Failure to Supervise and Report Missing Resident
Penalty
Summary
The facility failed to provide adequate supervision and follow their policy and procedure for a missing resident and elopement, resulting in a resident being unaccounted for two days. The resident, who had diagnoses including Schizoaffective Disorder, muscle weakness, Dysphagia, and PTSD, signed out of the unit without specifying his destination and was not reported missing until the following day. The night shift nurse was aware that the resident was out of the unit all night but did not alert anyone or document the absence, leading to a delay in initiating the missing resident policy. Interviews with staff revealed a lack of communication and adherence to the facility's procedures. The night shift nurse did not inform the night shift supervisor or the incoming staff about the resident's absence. The Certified Nurse Assistant (CNA) assumed the resident was with the Office of Public Safety (OPS) and did not report the resident missing. The Licensed Vocational Nurse (LVN) was aware of the resident's absence but did not report it to the Supervising Registered Nurse (SRN) or follow the policy for missing residents. The facility's policy required staff to conduct hourly rounds and report any missing residents within two hours. However, the staff failed to follow these procedures, resulting in the resident being without scheduled and as-needed medications for two days. The Director of Nursing (DON) confirmed that the facility's policy was not followed, as staff did not start searching for the resident or notify the family when the resident did not return at the expected time.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Live roaches were found in multiple areas of the kitchen, including under the stainless-steel counter, behind the ice machine, and in the dishwashing room. The presence of pests was attributed to construction across the street and a door leading to the dumpsters being propped open. The facility's policy indicated that the kitchen should be free of pests, but this was not adhered to, leading to potential contamination of food and food-contact surfaces. The floors in various areas of the kitchen, including under counters, behind equipment, and in the housekeeping closet, had a build-up of food crumbs, trash, and grime. This build-up can attract pests and allow pathogenic microorganisms to grow. The facility's policy required that the kitchen and serving areas be kept clean and free from litter and rubbish, but this was not followed. Observations revealed that housekeeping practices were insufficient to maintain cleanliness, with pressure washing occurring only once a month. The facility also failed to properly document the cooling process for food items. The Cook Specialist II did not log the time and temperature of food items placed in the blast chiller, and the cooling temperature log was incorrectly filled out by multiple employees. This failure to document and monitor the cooling process can lead to microbial growth in time/temperature control for safety foods. Additionally, nursing staff were observed handling ready-to-eat food with their bare hands, which can contribute to the transmission of foodborne illness. The facility did not have a policy in place to prevent bare hand contact with ready-to-eat foods, further increasing the risk of contamination.
Persistent Roach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent roach infestation in the [NAME] staging kitchen since 6/8/23. Observations on 4/8/24 revealed multiple sticky traps containing live roaches, a build-up of food crumbs, trash, and spilled liquid under equipment, and drains with black grime and food. The Pest Technician from [company name] pest control services confirmed the presence of German Cockroaches, particularly around the dishwasher, and noted that a door leading to the dumpsters was often propped open, allowing pests to enter the kitchen. This situation was corroborated by a facility work order dated 6/8/24, which indicated an increase in cockroach sightings in the dish room area and surrounding hallways. The facility's policy on Food and Nutrition Services-Sanitation, dated 11/5/23, stated that kitchen and serving areas should be protected from pests. Additionally, the FDA Federal Food Code (2022) mandates that premises be maintained free of pests and that effective measures be taken to eliminate their presence. Despite these guidelines, the facility's failure to address unsanitary conditions and secure entry points allowed the infestation to persist, posing a risk of disease transmission to 197 medically compromised residents who received food from the kitchen.
Failure to Ensure Call Lights Were Within Reach in Restrooms
Penalty
Summary
The facility failed to provide reasonable accommodations for residents by not ensuring that call lights were within reach in the restrooms. During an observation, the call-light pull-cords for several residents were found dangling from the wall and not properly latched to the toilet railing. This issue was confirmed during an interview with a Certified Nursing Assistant (CNA) who demonstrated the improper placement of the call-light. Additionally, a Registered Nurse (RN) stated that staff direct residents to use the call-light for assistance after being given privacy in the restroom. The facility's policy indicated that each resident should have a readily accessible call-light, which was not adhered to in this case.
Failure to Maintain Clean Equipment
Penalty
Summary
The facility failed to ensure a clean environment in two specific instances. First, a visibly soiled wheelchair with a dried brown substance on the seat cushion was observed stored in a hallway. Despite the facility's policy indicating that wheelchairs should be cleaned as needed and thoroughly every month, the soiled wheelchair was not cleaned. Staff members, including the MDS Coordinator and a Supervising Registered Nurse, acknowledged the issue but did not take immediate action to clean the wheelchair during the observation. Second, staff failed to clean resident lift equipment after use. A Certified Nursing Assistant (CNA) used the lift equipment on two separate occasions to transfer residents but did not clean the equipment before storing it away. This was contrary to the facility's policy, which requires cleaning lift equipment after each use. Both the CNA and a Registered Nurse confirmed that the policy mandates the use of microbial wipes before and after using all devices, but the CNA did not follow this procedure during the observed instances.
Failure to Conduct Timely Significant Change in Status Assessment
Penalty
Summary
The facility failed to conduct a Significant Change in Status Assessment (SCSA) within 14 days for Resident 159 after the emergence of a new unstageable pressure injury and unplanned weight loss. The resident's physician orders indicated the need for a wound consult, and the care plan noted the onset of the pressure injury. However, the facility did not convene an interdisciplinary team (IDT) meeting to address the wound progress and update the care plan as required by their policy. Interviews with staff revealed that there was no IDT meeting specifically for pressure ulcers, and the MDS Coordinator was not notified of the change in condition. Additionally, the facility failed to initiate a change of status IDT/MDS for Resident 159's significant weight loss. The dietary follow-up report and weight record indicated significant weight loss, but the facility's policy on weight monitoring was not followed. Staff interviews indicated confusion about whether significant weight loss would trigger a significant change assessment and revealed that the weight team, rather than the IDT, handled notifications. The need for an MDS assessment was missed due to a lack of communication in an IDT meeting.
Failure to Update Comprehensive Care Plan
Penalty
Summary
The facility failed to update the comprehensive care plan for Resident 120 to accurately reflect the assistive devices required. Resident 120, who was admitted with diagnoses of age-related cognitive decline, generalized muscle weakness, and spondylosis of the thoracic region, was observed multiple times using a wheelchair for ambulation. However, the care plan dated 4/5/24 incorrectly indicated that the resident used a four-wheel walker (4WW) for mobility. This discrepancy was confirmed by the Supervising Registered Nurse (SRN 4) during a record review and interview on 4/11/24. Additionally, the resident's room was observed on multiple occasions, and no 4WW was found. The resident's family member expressed concerns about the resident's prolonged use of a wheelchair and the need for rehabilitation. The facility's policy and procedure on care plans, dated 2/13/24, mandates that each discipline is responsible for ongoing follow-up to ensure services are furnished to attain or maintain the resident's highest practicable physical well-being. The failure to update the care plan resulted in the inability to track the resident's progress and provide continued comprehensive care.
Failure to Revise Care Plan for Wound Care Orders
Penalty
Summary
The facility failed to revise the care plan for one resident when the resident's wound care orders were changed. The resident had bilateral heel wounds from ischemia and peripheral arterial disease. The physician orders indicated that the wound care should be applied every other day with a generous amount of betadine and that the old orders should be discontinued. However, the care plan, dated earlier, still indicated that the treatment should be applied four times a day. During an interview and record review, the MDS Coordinator confirmed that the care plan should have been updated to reflect the new wound care orders. The facility's policy and procedure stated that each discipline is responsible for the initiation and ongoing follow-up for the care plan.
Failure to Provide Community Activities for Resident
Penalty
Summary
The facility failed to provide community activities for one resident, which had the potential to prevent the resident from obtaining a meaningful connection with his community and improving his quality of life. The resident expressed dissatisfaction with the facility's activities program, noting that there were previously many activities to choose from, including outdoor experiences and outings to dinner and culinary schools. The resident specifically mentioned a desire to visit a nearby firehouse, which had not been facilitated in the last three years despite multiple requests. The Recreational Therapist acknowledged the resident's preferences for community outings and explained that due to COVID-19 and flu concerns, the facility had reduced the number of outings. Additionally, transportation issues were cited as a barrier, with the resident's wheelchair being too large for the private transportation company's lift and the state shuttle being short-staffed and only available for medical appointments. A review of the resident's care plan and activity participation log confirmed that the resident had not participated in any community outings as requested in the past three months.
Failure to Ensure Timely Audiology Assessment and Hearing Aid Replacement
Penalty
Summary
The facility failed to ensure an audiology assessment was conducted and the right hearing aid was replaced in a timely manner for Resident 120. Resident 120, who was admitted with diagnoses of Age-Related Cognitive Decline and Sensorineural Hearing Loss, was observed without his hearing aids. The resident mentioned that his hearing aids were missing, and it was confirmed by a registered nurse that the right hearing aid had been missing for a while, and the left hearing aid had a dead battery. The resident's family member stated that the hearing aid had been missing since November of the previous year and that multiple requests for an audiology appointment had been made without any follow-up from the facility. The medical record review indicated that an audiology referral was ordered on 11/30/23, but no pending appointment or referral request was found in the system. The facility's policy and procedure for processing incoming orders were not followed, as the audiology referral was not properly scheduled. The supervising registered nurse confirmed that there was no pending appointment for audiology in the system, despite the referral being inputted five months prior. This lack of follow-up resulted in Resident 120 not receiving the necessary audiology assessment and replacement of the hearing aid in a timely manner.
Delay in Physical Therapy Evaluation for Resident
Penalty
Summary
The facility failed to provide Physical Therapy (PT) per physician's order in a timely manner for Resident 120, resulting in a delay of care for over a month. Multiple observations between 4/8/24 and 4/11/24 showed Resident 120 sitting in a wheelchair and requiring assistance for ambulation. The resident was not observed using any other assistive devices. A Restorative Nurse Referral Note dated 1/7/24 indicated a care plan for range of motion exercises and ambulation with a four-wheeled walker (4WW) and stand-by assistance. An Interdisciplinary Team Conference Note dated 2/19/24 highlighted the resident's weak gait and high risk for falls. On 3/2/24, an Interdisciplinary Progress Note indicated that the resident returned to the facility appearing weak, and a PT evaluation was ordered on 3/3/24 due to weakness and mobility issues. However, the first PT assessment did not occur until 4/8/24, and the resident was not fully assessed at that time due to participation in other activities. This delay in PT evaluation contributed to the resident's prolonged use of a wheelchair and decline in mobility. During an interview on 4/10/24, a family member of Resident 120 mentioned that the resident had COVID a month ago and had been in a wheelchair since returning to their usual room. The family member expressed concerns about the resident's increasing weakness. A concurrent interview and record review on 4/11/24 with the Supervising Registered Nurse 4 (SRN 4) confirmed that the PT evaluation should have been conducted by now. The facility's policy and procedure for Physical & Occupational Therapy Services, dated 7/31/23, stated that PT/OT evaluations should be conducted within 5 business days of the physician's order, which was not adhered to in this case.
Discontinued Insulin Sliding Scale Carried Over to Current Order
Penalty
Summary
The facility failed to ensure a discontinued Novolin R Insulin Sliding Scale was not carried over to the current physician's order for one resident. During a review of the resident's current physician's recapitulation order, it was found that two different Novolin R Insulin Sliding Scales were listed, one of which had been discontinued. The Nurse Practitioner confirmed that the undated sliding scale was discontinued previously and should not have been included in the current order. This oversight had the potential for medication administration error.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were properly stored when a resident's Voltaren, a topical medication for pain, was found without a cap in a container with other residents' medications. During an observation and interview with the MDS Coordinator, it was noted that the medication should have a cap to keep it moist and clean. The facility's policy and procedure indicated that drug containers which are cracked, soiled, or without secure closures should not be used. This failure had the potential to result in medication contamination and compromised effectiveness.
Failure to Maintain Transmission Based Precautions
Penalty
Summary
The facility failed to maintain Transmission Based Precautions for two residents. An Xray Technician (XT) did not wear the required Personal Protective Equipment (PPE) while providing care for Resident 156, who was on droplet isolation precautions. The XT was observed performing a procedure wearing only a surgical mask and came in direct contact with Resident 156. The XT stated that they were unaware of the need to wear PPE, and the Infection Control Preventionist (ICP) confirmed that the XT, although a contractor, should have been wearing the PPE. The facility's policy indicated that staff should follow CDC PPE Sequence Guidance, which was not adhered to in this instance. Additionally, Resident 130 was exposed to contaminated PPE due to the placement of a PPE disposal bin obstructing the path to his bed. Resident 130, who was in a wheelchair, repeatedly bumped into the bin and eventually reached into it, touching the used PPE without washing his hands or using hand sanitizer. The ICP and a Licensed Vocational Nurse (LVN) acknowledged that the bin was typically kept by the door but could be moved if it obstructed the resident's path. The facility's policy stated that PPE should be disposed of upon exiting the room and hand hygiene should be performed, which was not followed in this case.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for its residents. During an observation on Unit 1D, three windows near the main entrance were found to be visibly soiled from the outside and had spider webs on the inside. This was confirmed by the Supervising Registered Nurse (SRN 1) and Housekeeping staff, who admitted that the windows had been dirty for about three months. The facility's policy and procedure on environmental cleaning, dated January 1, 2024, mandates maintaining a clean and homelike environment, which was not adhered to in this case. In another instance, a plastic urinal in room [ROOM NUMBER] was found unlabeled and undated on Resident 188's side table. SRN 3 confirmed that the urinal should have been labeled with the resident's name and dated. The facility's policy on environmental cleaning, dated January 2024, requires urinals to be cleaned after each use, replaced weekly, and labeled with the resident's name and projected change date. This policy was not followed, resulting in an unsanitary condition for Resident 188.
Failure to Ensure Timely Medical Follow-Ups and Proper Hygiene
Penalty
Summary
The facility failed to ensure timely cardiology follow-up for Resident 597 after a fall, as ordered by the physician. Despite the physician's order for a cardiology consult on 2/6/24, the appointment was scheduled for 4/24/24, which was not timely given the resident's recent falls and history of atrial fibrillation. The Chief of Medical Records acknowledged that the appointment should have been moved up and that the scheduling protocol was not followed correctly, leading to a delay in necessary medical evaluation for Resident 597. Additionally, Resident 597 did not receive a timely referral to neurosurgery as recommended by the physician. After a fall resulting in thoracic/lumbar compression fractures and right rib fractures, a spine ortho referral was declined, and the resident was advised to follow up with neurosurgery. However, there was no evidence that this follow-up was completed, and the Chief of Medical Records confirmed that the care team was notified but did not provide information on any further action taken. Resident 71's compression stockings were not changed regularly or when visibly soiled, as observed during an interview. The resident's right lower extremity compression stocking was visibly soiled with a large brown stain, and the resident confirmed that the stocking had not been changed for a while. The Supervising Registered Nurse acknowledged that the stockings should be changed when soiled, but this was not done, leading to potential skin irritation for Resident 71.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident had an updated Care Plan, which had the potential to place the resident at risk for preventable falls and potential injury. The Occupational Therapy (OT) Evaluation Note dated 2/12/24 indicated that the resident would benefit from Stand By Assist (SBA) to Contact Guard Assist (CGA) for out-of-bed mobility and activity/transfers/functional ambulation for safety. The OT also recommended line-of-sight supervision from nursing staff. However, these recommendations were not incorporated into the resident's Care Plan. During an interview, the Occupational Therapist confirmed that she made these recommendations but did not write orders, leaving it to the rest of the medical team to decide on the implementation. A review of the resident's Care Plan with a run date of 1/13/24 showed that the interventions for Activities of Daily Living function were last updated on 7/29/23, with the exception of a Neurology department consult on 12/12/23. The Supervising Registered Nurse (SRN) confirmed that the OT's recommendations from 2/5/24 were not added to the Care Plan. This oversight meant that the necessary assistance and supervision for the resident were not documented, potentially compromising the resident's safety and care.
Failure to Provide Timely OT Evaluation and Follow Recommendations
Penalty
Summary
The facility failed to ensure that a resident received a timely occupational therapy (OT) evaluation and that the OT recommendations were followed. An OT evaluation order was placed on January 8, 2024, for a resident diagnosed with weakness. However, the evaluation was not completed until February 5, 2024, despite multiple attempts. According to the facility's policy, evaluations for acute conditions should be completed within five business days. This delay in evaluation contributed to several potentially preventable falls for the resident. The OT evaluation on February 5, 2024, recommended that the resident receive stand-by assistance (SBA) to contact guard assistance (CGA) for mobility and line-of-sight supervision from nursing staff. However, these recommendations were not incorporated into the resident's care plan. The care plan was last updated on July 29, 2023, and did not reflect the OT's recommendations. Subsequent falls on February 18, 24, and 25, 2024, did not prompt updates to the care plan to include the OT's recommendations. Interviews with staff revealed that the process for updating care plans following OT evaluations and falls was not followed. The OT recommendations were discussed with the RN on duty but were not documented in the care plan. The interdisciplinary team (IDT) meetings did not review the care plan in its entirety, focusing only on specific issues related to falls. This lack of comprehensive review and documentation led to the resident not receiving the necessary supervision and assistance, contributing to multiple falls.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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