View Heights Conv Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 12619 S. Avalon Blvd, Los Angeles, California 90061
- CMS Provider Number
- 056417
- Inspections on file
- 38
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at View Heights Conv Hosp during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and alcohol dependence, under a public guardian, was allowed to leave the facility on an Out on Pass without the required OOP Request Form and signatures from the interdisciplinary team in the clinical record. Staff interviews and record review confirmed the absence of this documentation, which is mandated by facility policy to ensure proper assessment and authorization before a resident leaves the facility.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with intact cognition and multiple diagnoses reported a lump at the back of the neck, which was brought to staff attention by a family member and the County Case Manager. Despite these notifications, an RN failed to assess the correct area, did not document the assessment, and did not notify the physician or respond to follow-up inquiries, resulting in a lack of timely evaluation and documentation as required by facility policy.
Staff did not monitor or document the aggressive behaviors of a resident with schizoaffective disorder and cognitive impairment, despite physician orders and facility policy. This failure was identified after the resident struck another resident and expressed intent to repeat the behavior. Staff interviews confirmed the resident's history of aggression and the lack of required monitoring.
The facility failed to provide a diet meeting residents' nutritional needs by serving a breakfast lacking adequate nutritional value and not having a system to ensure meal substitutes were of equal nutritive value. A mc muffin sandwich without meat was served, and the Dietary Supervisor was unaware of the requirement for sausage. Additionally, the facility lacked a nutritional analysis for meals, making it difficult to ensure alternatives were nutritionally adequate, potentially risking residents' nutritional status.
The facility employed a dietary supervisor (DS) who did not meet the required qualifications, such as having an associate's degree or certification in food service management. The DS, previously a cook, was overseeing kitchen activities and residents' dietary needs while still in school. The Registered Dietician was only present once a week, leaving the unqualified DS in charge on other days. The Director of Nursing was unaware of the educational requirements for the DS position.
The facility failed to provide breakfast sandwiches with sausage as per the menu for all residents. The Dietary Supervisor did not check the food before serving, and the Dietary Cook reported a lack of sausage in the kitchen. This oversight was a recurring issue, impacting the nutritional needs of residents.
The facility failed to ensure safe food storage practices, affecting all 146 residents. Observations revealed a walk-in refrigerator with unlabeled cheese, expired spinach, and undated lettuce, along with a dry storage room lacking a thermometer. Dietary staff confirmed these issues, and the facility's policies on food labeling and temperature monitoring were not followed, risking foodborne illnesses.
The facility's Arbitration Agreement failed to include a section for selecting a convenient venue for both parties, as discovered during an interview and record review. The Administrator admitted that the outdated agreement was provided to residents and their conservators, potentially causing bias in venue selection for binding arbitration agreements.
The facility failed to monitor washer water temperature and clean the dryer lint trap as per policy, leading to potential infection risks. The washer's temperature monitors were broken, preventing staff from ensuring proper disinfection of linen. Additionally, the dryer lint trap was not cleaned as required, which could affect the sanitizing process. The Infection Preventionist Nurse expressed concerns about the potential for improperly cleaned linen to cause infections among residents.
The facility failed to provide adequate seating in the dining room for all residents during mealtimes, resulting in some residents having to wait in line or return to their rooms until a seat became available. The dining room had only 40 chairs for 50 residents, leading to residents standing or being sent away, as confirmed by a CNA and the DON.
The facility failed to provide a dignified dining experience by not having enough seating for all residents, serving meals on disposable plates, and not ensuring simultaneous meal service at tables. Staff acknowledged these issues, which led to residents waiting for seats and meals, affecting their dignity.
The facility failed to obtain informed consent for psychotropic medications for three residents, resulting in the removal of their conservators' rights to make informed decisions. Informed consent forms were incomplete, lacking frequency and duration details for medications like Trazodone, haloperidol, Depakote, Buspirone, Ativan, and Zyprexa. This non-compliance with facility policy deprived conservators and guardians of necessary information for decision-making.
A facility failed to accurately document a resident's use of hypoglycemic medication in the MDS assessment. The resident, who had been receiving Insulin Glargine for type 2 diabetes, was not reported as being on this medication in the MDS. The MDS Coordinator confirmed the inaccuracy, which could affect the resident's care plan. Facility policy requires certification of assessment accuracy, which was not adhered to in this case.
A facility failed to create a care plan for a resident receiving Cymbalta for self-isolative behavior, despite no depression or anxiety diagnosis. The resident, with schizoaffective disorder, was independent and showed no aggressive behaviors. The DON admitted non-pharmacological interventions were not documented or attempted, contrary to facility policy, risking unnecessary medication use.
A resident with schizoaffective disorder was prescribed weekly Ozempic doses for diabetes management. An LVN documented the administration of the medication on a date prior to its actual administration, admitting to giving the dose a day late after the resident initially refused it. The facility's policy requires documentation only after administration, which was not followed.
The facility failed to monitor a resident's blood glucose before administering Insulin Glargine, risking hypoglycemia, and did not implement a physician's order for another resident's wound care, risking infection. The MAR did not prompt for glucose checks after a dosage change, and a wound care order was not transcribed, leading to these deficiencies.
A resident with schizophrenia, insomnia, and PTSD experienced a fall while walking to the dining room due to a loss of balance. Despite the facility's practice of conducting IDT conferences within seven days of an incident, no conference was held following the fall. The facility's policy requires investigations and interventions after a fall, but lacks a specific timeline for IDT conferences, potentially increasing the risk of recurrent falls.
Two residents in a LTC facility experienced medication administration errors. A resident received Ozempic from an expired pen, potentially affecting its effectiveness, while another resident was given Metformin too early, risking gastric distress. The facility's policies require medications to be administered as ordered, but these protocols were not followed.
The facility failed to monitor and document the use of psychotropic medications for two residents. One resident continued to receive Cymbalta without monitoring for depression or attempting a gradual dose reduction, despite the absence of symptoms. Another resident was prescribed haloperidol for schizophrenia without specifying the behaviors being treated, contrary to facility policy. The lack of documentation and clarification of medication orders led to potential unnecessary medication use.
A facility failed to manage a resident's Ozempic medication properly, as an injection pen was kept beyond its use-by date, and a Licensed Vocational Nurse did not label the pen with the correct open date. The resident, diagnosed with obesity, was prescribed Ozempic for weight management. The Director of Nursing confirmed that the pen should have been discarded after 56 days, and the incorrect labeling was acknowledged.
A facility failed to respect and document the food preferences and allergies of three residents, leading to potential health risks. One resident was not provided with a requested alternative meal, another's preference for fresh fruit as a snack was not documented or provided, and a third resident's dietary preferences and shrimp allergy were not properly documented, posing a risk of an allergic reaction. The facility's policies on food allergies and tray card systems were not adhered to.
The facility failed to provide snacks to two residents as requested, violating its Nourishment Policy. One resident, with schizoaffective disorder, was denied snacks outside scheduled times due to a lack of RD assessment. Another resident, also with schizoaffective disorder, was not given snacks despite expressing their importance. The DON confirmed that snacks should be provided when requested to prevent hunger and weight loss.
A facility failed to ensure a resident's conservator understood the Arbitration Agreement in their primary language, Spanish. The conservator, responsible for a resident with schizoaffective disorder and other dependencies, was given the agreement in English, which they did not fully comprehend. Although a translator explained the agreement, the conservator could not refer back to the document in Spanish, leading to a lack of understanding of the binding nature of the agreement.
The facility failed to report 24 COVID-19 positive residents to the CDPH as required, delaying the investigation and potentially increasing the spread of infections. Additionally, the facility did not implement its COVID-19 Mitigation Management Plan, as staff were observed not wearing masks properly. Interviews revealed a lack of awareness of reporting requirements, contributing to the deficiency.
A facility failed to report an abuse allegation involving a resident and staff to CDPH within the required two-hour timeframe. The resident, with schizoaffective disorder, reported being physically abused by staff after an incident of agitation. The DON cited fax transmission issues as the reason for the delay, which resulted in a delayed investigation by CDPH.
A resident with schizoaffective disorder experienced a delayed discharge due to the facility's failure to ensure proper planning and documentation for a transfer closer to family. Despite discussions with the resident's conservator and the interdisciplinary team, there was no follow-up or proof of communication with the DMH liaison regarding the necessary referral package. The facility lacked a process to document and track discharge planning, contrary to its policy.
The facility failed to meet professional standards of quality for two residents by not documenting one-to-one monitoring, repeating assessments over different time periods, and not updating vital signs after a change in condition. These actions were contrary to the facility's policies and negatively impacted the quality of care.
Two residents involved in a physical altercation did not receive proper care plan implementation. One resident, with schizoaffective disorder, was not monitored for shoulder swelling as required. The other resident, also with schizoaffective disorder, lacked documentation for medication side effects and hand assessment. The facility's policy mandates comprehensive care plans, but documentation was insufficient.
A resident exhibited inappropriate sexual behavior in a public area, but the facility failed to notify the physician or relevant medical professionals as required. The lapse occurred because the social services designee did not communicate the change to the nursing staff, resulting in a delay in care. The facility's policy requires prompt notification of changes in a resident's condition.
A resident with a history of hypersexual behavior was observed masturbating near another resident in a public area, with staff failing to intervene. Despite existing care plans and behavior plans, the facility did not effectively implement interventions or communicate changes in the resident's condition to medical staff, leading to repeated incidents of inappropriate behavior. This resulted in the affected resident experiencing anger and discomfort.
A resident with schizophrenia and COPD exhibited inappropriate sexual behavior in a public area of the facility. Despite a care plan that included attending therapeutic group meetings and modeling appropriate behaviors, the facility failed to document encouragement for these interventions or notify the resident's medical team after the initial incident. This led to repeated inappropriate conduct, causing distress to other residents.
Failure to Maintain Complete Clinical Records for Resident Out on Pass
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible clinical records for a resident who went Out on Pass (OOP) with a family member. The resident, who had a diagnosis of schizoaffective disorder and alcohol dependence and was under the care of a public guardian, had an approved OOP request for a specific date and time, as indicated by the Conservatee Leave Request form. However, upon review, the resident's clinical records did not contain the required OOP Request Form or the document titled 'Signing Residents Out on Pass' for the date in question. Interviews with facility staff, including the Social Services Assistant, Registered Nurse, Medical Records Assistant, and Director of Nursing, confirmed that the OOP Request Form, which should be signed by the Program Director, Social Services Director, and DON as part of the interdisciplinary team assessment, was missing from the resident's chart. Facility policy requires that the OOP Request Form be completed and signed by the appropriate team members to ensure the resident's safety and compliance with program requirements before leaving the facility. The absence of this documentation meant that the necessary assessment and authorization process was not properly documented or followed for the resident's OOP. This deficiency was identified through interviews and record reviews, which consistently indicated that the required documentation was not present in the resident's clinical records for the specified OOP event.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Assess and Document Resident's Neck Lump
Penalty
Summary
A deficiency occurred when a resident with a history of schizoaffective disorder, alcohol dependence, and nicotine dependence reported a lump at the back of his neck. The resident stated that a family member had likely informed the nurse about the lump. Despite an email from the County Case Manager to the facility's RN requesting an assessment of the lump, there was no documentation in the resident's progress notes indicating that an assessment was performed or that the physician was notified. The RN acknowledged receiving the request and stated that only the front of the resident's neck was checked, not the back where the lump was located. The RN did not document any findings or respond to the County Case Manager's follow-up email. The Director of Nursing confirmed that nurses are expected to assess residents when concerns are raised by family members and to document all findings and actions in the medical record. The facility's policies require comprehensive assessments and documentation of all services provided. In this case, the lack of timely assessment, failure to notify the physician, and absence of documentation regarding the resident's lump constituted the deficiency.
Failure to Monitor and Document Aggressive Behavior in Resident with Psychiatric Diagnosis
Penalty
Summary
Facility staff failed to monitor a resident with a known history of verbal and physical aggression, as ordered by the physician. The resident, diagnosed with schizoaffective disorder and exhibiting cognitive impairments, had a physician order in place requiring staff to monitor and document episodes of verbal and physical aggression. Despite this order, review of the behavior monitoring flowsheet revealed that staff did not document or monitor the resident's aggressive behaviors. The Director of Nursing confirmed that the monitoring was not completed as required, and the purpose of the monitoring was to identify escalating behaviors and prevent further incidents. This deficiency was highlighted when the resident struck another resident in the face without provocation and expressed a desire to hit someone again. Interviews with staff indicated that the resident had a history of aggressive behavior and was considered a safety risk to others. Facility policies required monitoring of residents at risk for unsafe behavior, but these procedures were not followed, resulting in a lack of documentation and monitoring for the resident's aggression.
Deficiency in Nutritional Value of Meals and Lack of Nutritional Analysis System
Penalty
Summary
The facility failed to provide a diet that met the nutritional needs of all residents by not ensuring that breakfast offered adequate nutritional value and by lacking a system to ensure meal substitutes and alternatives were of equal or nutritive value. During an observation, it was noted that a mc muffin sandwich without meat was served to residents, containing only scrambled eggs. The Dietary Supervisor (DS) and Dietary Cook (DC) acknowledged the absence of sausage, which was supposed to be part of the meal, and admitted that this issue had occurred previously. The DS was unaware that the sandwich required meat and failed to check the food served to residents, which was crucial to prevent weight loss. Additionally, the facility did not have a system to determine the nutritional values of the menus provided to residents. The Registered Dietician (RD) confirmed that the facility lacked a nutritional analysis for the meals served, making it difficult to ensure that meal alternatives like peanut butter sandwiches, grilled cheese sandwiches, or chef's salads were of similar nutritive value. The RD stated that without knowing the nutritional content of the planned menu and alternatives, there was a potential risk for residents to experience malnourishment and loss of muscle mass. The Director of Nursing (DON) emphasized that meals should meet residents' nutritional needs to prevent undesired weight loss.
Unqualified Dietary Supervisor Employed
Penalty
Summary
The facility failed to employ a dietary supervisor (DS) who met the necessary qualifications, which include having an associate's degree or higher in food service management or hospitality, being a certified dietary manager, certified food service manager, or having national certification for food service management and safety. The DS was recognized only for completing a basic food handler course and was still enrolled in relevant courses, indicating she was not yet qualified for the position. Despite this, she was overseeing kitchen activities and residents' dietary needs while still in school. Interviews revealed that the DS began working in December 2024 and was previously a cook at the facility. The Registered Dietician (RD) was only present at the facility on Tuesdays, leaving the DS in charge on other days despite her lack of qualifications. The Director of Nursing (DON) admitted to not knowing the educational requirements for the DS position and confirmed that the DS was not qualified. The facility's job description for the Director of Food Services required the DS to be a graduate of an accredited course in dietetic training and registered as a food service director in the state, which the current DS did not fulfill.
Failure to Follow Dietary Menus for Breakfast
Penalty
Summary
The facility failed to ensure that dietary staff followed the dietary menus for all 146 residents by not providing a breakfast sandwich with sausage as specified in the menu. During an observation, it was noted that the breakfast sandwiches served contained only scrambled eggs, lacking the sausage patty that was required according to the facility's recipe and menu. The Dietary Supervisor (DS) was unaware that the breakfast sandwich was supposed to include sausage and did not check the food before it was served to residents. This oversight was confirmed during an interview with the DS, who admitted to not noticing the absence of sausage in the breakfast sandwiches. Further investigation revealed that the Dietary Cook (DC) was aware that the breakfast sandwich should have included sausage but did not have any available in the kitchen. The DC had informed the DS about the lack of sausage, yet the sandwiches were still served without it. This issue had occurred previously, indicating a recurring problem with food supply or menu adherence. The facility's policy and procedure for menu planning, as well as the job descriptions for the cook and the Director of Food Services, emphasize the importance of following menus to meet residents' nutritional needs, which was not adhered to in this instance.
Deficient Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, affecting all 146 residents. During an initial kitchen tour, surveyors observed several deficiencies, including a walk-in refrigerator containing a bag of cheese without a use-by date, expired bags of spinach, and unlabeled lettuce. Additionally, the dry storage room lacked a thermometer to monitor room temperature, which is essential for ensuring food safety. Interviews with dietary staff confirmed these observations, with the dietary cook acknowledging the absence of proper labeling and the expired spinach, and the dietary supervisor emphasizing the importance of dating food items to prevent serving old food to residents. The facility's policies and procedures for dry storage and refrigerated storage were not followed, as evidenced by the lack of a thermometer in the dry storage room and the improper labeling and dating of food items in the refrigerator. The facility's policy indicated that storeroom temperatures should be maintained between 50 to 70 degrees Fahrenheit and that a thermometer must be present to monitor these temperatures. Furthermore, the policy required that all food items in the refrigerator be covered, labeled, and dated to ensure they are used within the correct timeframe. The failure to adhere to these policies had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illnesses to all residents receiving food from the kitchen.
Arbitration Agreement Lacks Venue Selection
Penalty
Summary
The facility failed to include a selection of a venue that was convenient to both parties in their Arbitration Agreement, which is meant to resolve disputes between the facility and residents through a neutral arbitrator rather than going to court. During an interview and record review, it was found that the facility's Resident-Facility Arbitration Agreement, which was undated, did not reflect the updated version that included this crucial section. The Administrator acknowledged that the facility's administration was responsible for providing the updated agreement to the Admissions Coordinator, who would then review it with the resident and their conservator. However, the residents and their conservators were given the outdated version of the agreement, potentially causing bias in the venue selection process for those entering into a binding arbitration agreement.
Failure to Monitor Laundry Water Temperature and Clean Dryer Lint Trap
Penalty
Summary
The facility failed to adhere to its Water Temperature Policy for Facility Laundry and Preventative Maintenance Policy, leading to potential infection risks. On 2/14/2025, it was observed that the washer water temperature monitors were broken, preventing staff from ensuring that the water temperature was maintained between 125-165 degrees Fahrenheit as required. The Maintenance Supervisor (MS) admitted that staff were unable to verify if the linen was being properly cleaned or disinfected due to the lack of temperature monitoring. Additionally, the MS mentioned that the facility relied on the chlorine in the washing solution for disinfection, but acknowledged uncertainty about the effectiveness without knowing the water temperature. Furthermore, the facility did not follow its policy regarding the cleaning of the dryer lint trap. On the same day, it was observed that the lint trap contained lint, and the MS confirmed that staff were supposed to clean the lint trap twice per shift, starting at 5:30 a.m. However, the dryer lint removal log showed no documentation of cleaning at 7 a.m. or 9 a.m. The MS stated that failing to clean the lint trap could lead to a fire risk and affect the dryer temperature, potentially compromising the sanitizing process of the linen. The Infection Preventionist Nurse (IPN) expressed concerns that the dryer might not kill all bacteria and viruses if the lint trap was not clean, and that the uncertainty about the washer water temperature could result in improperly cleaned linen, posing an infection risk to residents.
Inadequate Dining Room Seating
Penalty
Summary
The facility failed to accommodate all residents in the dining room during mealtimes, as observed on multiple occasions. The dining room was equipped with only 40 chairs, while the north side of the facility housed 50 residents. This lack of seating resulted in residents having to wait in line or be sent back to their rooms until a seat became available. On several occasions, residents were observed standing in the dining room or at the entrance, waiting for a seat, and were instructed by a Certified Nursing Assistant (CNA) to wait against the wall or return to their rooms. Interviews with the CNA and the Director of Nursing (DON) confirmed that the dining room could not accommodate all residents simultaneously, leading to the practice of having residents wait or return to their rooms. The DON acknowledged that this practice could negatively impact residents' feelings, as they were made to wait to eat. The facility's policy indicated that meals should be distributed promptly and that residents should be encouraged to sit in a dining room chair, highlighting a discrepancy between policy and practice.
Dining Experience Deficiencies Affect Resident Dignity
Penalty
Summary
The facility failed to provide a dignified dining experience for residents, as observed during multiple instances where the dining room did not have enough space or seating for all residents to eat at the same time. Residents were seen waiting in line or being sent back to their rooms due to insufficient seating. Staff, including a CNA and the DON, acknowledged the lack of space and chairs, which led to residents having to wait against the wall or return to their rooms until a seat became available. Additionally, the facility did not ensure that all residents sitting at the same table received their meals simultaneously. Observations showed that staff distributed food trays in a disorganized manner, skipping some residents and causing delays. The DON admitted there was no specific process for distributing food trays, which resulted in some residents having to wait longer for their meals. The facility also used disposable plates and bowls due to a shortage of regular plates, which was against the facility's policy. This practice was acknowledged by the DS and DC 2, who stated that it was not appropriate and did not provide a homelike environment. The use of disposable items was only meant for extenuating circumstances, yet it was observed during regular meal service, potentially affecting residents' dignity and self-worth.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to three residents, which resulted in the removal of their conservators' rights to make informed decisions about their care. Resident 31 was administered Trazodone without prior informed consent from their conservator. The facility's policy required informed consent to be obtained and verified before the initial administration of psychotropic medication, but this was not done for Resident 31. Additionally, the Verification of Informed Consent forms for Resident 31 were incomplete, lacking the frequency of administration for Trazodone, haloperidol, and Depakote. Resident 16's informed consent forms for Buspirone, Ativan, and Zyprexa were also incomplete, missing the frequency of administration. Despite having intact cognitive skills for daily decision-making, Resident 16 had a public guardian responsible for their care. The facility's failure to include the frequency of medication on the informed consent forms deprived the public guardian of the necessary information to make informed decisions about the resident's treatment. Similarly, Resident 347's informed consent form for Zyprexa was incomplete, lacking the frequency and duration of administration. Resident 347, who had intact cognitive skills for daily decision-making, also had a public guardian. The facility's policy required that the nature of the procedures, including their probable frequency and duration, be included in the informed consent. The absence of this information on the informed consent forms for all three residents indicates a failure to comply with the facility's policy and deprived the conservators and guardians of their right to make informed decisions about the residents' care.
Inaccurate MDS Assessment for Resident on Hypoglycemic Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, identified as Resident 31, by not indicating that the resident was on hypoglycemic medication. This inaccuracy was discovered during a review of the resident's records, which showed that the MDS did not reflect the resident's ongoing treatment with Insulin Glargine, a medication used to manage type 2 diabetes mellitus. The resident's Admission Record and Order Recap Report confirmed the use of Insulin Glargine, which had been administered for an extended period. The Minimum Data Set Coordinator (MDSC) acknowledged the discrepancy during an interview and record review, confirming that the MDS inaccurately reported the resident's medication status. The facility's policy requires all personnel completing any part of the Resident Assessment to certify its accuracy, highlighting a lapse in adherence to this policy. This failure had the potential to negatively impact the resident's plan of care and the delivery of necessary services related to diabetes management.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a care plan for a resident who was administered Cymbalta for self-isolative behavior, despite the absence of a diagnosis of depression or anxiety. The resident, who was admitted with a diagnosis of schizoaffective disorder, did not exhibit cognitive impairments or aggressive behaviors and was independent in mobility and eating. The physician's order for Cymbalta was based on self-isolative behavior, yet no care plan was created to address this behavior or to explore non-pharmacological interventions prior to the use of psychotropic medication. The Director of Nursing acknowledged the absence of a care plan and stated that non-pharmacological interventions, such as counseling and group activities, should have been attempted and documented before resorting to medication. The facility's policies emphasized a holistic approach to behavior management, requiring thorough assessment and individualized interventions. The lack of a care plan placed the resident at risk of receiving unnecessary medication and potential side effects, as non-drug approaches were not documented or attempted as per the facility's guidelines.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration by a Licensed Vocational Nurse (LVN) for a resident. The resident, who was diagnosed with schizoaffective disorder and had no cognitive impairments, was prescribed a weekly dose of Ozempic for type 2 diabetes management. The Medication Administration Record (MAR) indicated that the resident received the scheduled doses on specific dates. However, an observation revealed that the Ozempic injection pen was empty, and a sealed pen was found unused, indicating a discrepancy in the administration record. Further investigation showed that the LVN documented the administration of the medication on a date prior to its actual administration. The LVN admitted to administering the dose a day later than scheduled after the resident initially refused and then agreed to take the medication. The Director of Nursing confirmed that medications should be documented as administered only after they are given, as per the facility's policy. This failure in documentation had the potential to delay the resident in reaching her care goals.
Failure to Monitor Blood Glucose and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure quality care for two residents by not clarifying and monitoring blood glucose levels for one resident and not implementing a physician's order for wound treatment for another. For Resident 31, the facility did not monitor blood glucose levels before administering Insulin Glargine on multiple occasions. The Licensed Vocational Nurse (LVN) acknowledged that the Medication Administration Record (MAR) did not prompt for blood glucose checks after the insulin dosage was changed, leading to potential risks of hypoglycemia. Resident 31 was admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, and hyperlipidemia. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and independence in daily activities. Despite the change in insulin dosage, the MAR failed to include a prompt for blood glucose monitoring, which was a standard practice when the resident was on a higher insulin dose. The facility's policy required clarification of any discrepancies in medication orders, which was not adhered to in this case. For Resident 16, the facility did not follow the physician's order to cleanse a scalp wound daily, which was not transcribed to the MAR. The resident, who had a history of schizoaffective disorder and diabetes mellitus, was observed with dried blood and staples on the scalp, indicating the wound had not been cleansed since hospital discharge. The Infection Preventionist Nurse confirmed the risk of infection due to the lack of wound care. The facility's policy required that all physician orders be added to the MAR or treatment record, which was not done in this instance.
Failure to Conduct IDT Conference After Resident Fall
Penalty
Summary
The facility failed to conduct an Interdisciplinary Care Team (IDT) conference following a witnessed fall involving a resident on December 19, 2024. The resident, who was diagnosed with schizophrenia, insomnia, and PTSD, experienced a fall while walking to the dining room for breakfast due to a loss of balance. Despite having intact cognitive skills for daily decision-making and being independent in most activities, the resident required setup assistance with oral and personal hygiene and experienced hallucinations, delusions, and disorganized thinking. The resident also expressed the importance of having family or a close friend involved in care discussions. The Director of Nursing (DON) confirmed that no IDT conference was conducted for the fall incident, which is contrary to the facility's practice of holding such conferences within seven days of an incident to prevent recurrence. The facility's Fall Management System policy, approved in April 2023, mandates that investigations and appropriate interventions be initiated at the time of a fall and reviewed by Nursing Management in subsequent meetings. However, the policy does not specify a timeline for conducting an IDT conference after a fall. The lack of an IDT conference following the fall had the potential to increase the risk of recurrent falls for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. For Resident 56, a Licensed Vocational Nurse (LVN) administered five doses of Ozempic, a medication used to treat type 2 diabetes mellitus, from an injection pen that was 35 days beyond its use-by date. This was observed during a review of the medication cart and storage room, where it was noted that the pen should have been discarded after 56 days of opening. The Director of Nursing (DON) confirmed that using the expired pen could lead to decreased effectiveness of the medication, potentially affecting the resident's weight loss treatment. For Resident 49, the facility failed to administer Metformin, a medication for diabetes, at the correct time. The medication was given more than one hour before the scheduled administration time, which was supposed to coincide with meals. The DON stated that the medication should be administered with or immediately after meals to avoid gastric distress. The early administration was observed, and it was noted that dinner was not served until later, indicating the medication was given on an empty stomach. The facility's policies and procedures, as well as the job description for LVNs, require medications to be administered as ordered by the physician and within a specific time frame. The observed deficiencies in medication administration for both residents highlight a failure to adhere to these protocols, potentially compromising the residents' health outcomes.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. For Resident 3, the staff did not monitor for self-isolating behaviors and did not attempt a gradual dose reduction (GDR) for Cymbalta, which was prescribed for depression. Despite the absence of depression symptoms, as indicated in the Psychotropic Monthly Summary assessments, the medication was continued without documented monitoring or a GDR attempt. The Director of Nursing (DON) acknowledged the lack of documentation and monitoring, stating that a GDR should have been completed if the behavior was not present. For Resident 31, the facility failed to document behavior manifestations for the use of haloperidol, an antipsychotic medication prescribed for schizophrenia. The medication order did not specify the behaviors being treated, which is necessary for appropriate monitoring and care. The Registered Nurse (RN) and DON both stated that the order should have been clarified to include specific behaviors, as the diagnosis alone was not a sufficient indication for the medication. The order for haloperidol had been active since 2018 without clarification. The facility's policy on psychotropic medication use requires that such medications be used to treat specific behaviors and symptoms, with clinical indications and at the lowest possible doses. However, the facility did not adhere to this policy for Residents 3 and 31, as there was a lack of monitoring, documentation, and clarification of medication orders, leading to the potential for unnecessary medication use.
Medication Management Deficiency: Improper Labeling and Disposal of Ozempic Pen
Penalty
Summary
The facility failed to properly manage the medication of a resident, specifically concerning the use and labeling of an Ozempic injection pen. The Ozempic pen, used to treat type 2 diabetes mellitus, was kept in the medication cart beyond its use-by date of 12/31/2024. Additionally, a Licensed Vocational Nurse (LVN) did not label the pen with the correct open date, which could lead to the administration of medication with reduced potency. During an observation, it was noted that the pen was opened on 11/5/2024 and was empty, yet it was still present in the cart without a replacement. The facility's Director of Nursing confirmed that the pen should have been discarded after 56 days, and the incorrect labeling of the open date was acknowledged. The resident involved, who was admitted with a diagnosis of obesity, was prescribed Ozempic to be administered every seven days. The Medication Administration Records indicated that the resident received five doses from the pen opened on 11/5/2024. The failure to dispose of the pen after the recommended period and the incorrect labeling of the new pen's open date were identified as deficiencies. The Director of Nursing emphasized that the medication should not be used past its use-by date to ensure its effectiveness, particularly for the resident's weight loss treatment.
Failure to Document and Respect Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to respect and document the food preferences and allergies of three residents, leading to potential health risks. Resident 97 was not provided with a requested alternative meal of cheese quesadillas, despite the kitchen having the necessary ingredients. The resident's preference was not documented in the diet order, and the available alternatives did not meet the resident's satisfaction, potentially risking malnutrition. The Registered Dietician (RD) confirmed that the substitution process was not followed correctly, and the resident's nutritional needs were not met. Resident 51 expressed a preference for fresh fruit as a snack, which was not documented or provided. The RD was unaware of this preference, and there was no system in place to ensure that residents' food preferences were assessed and documented. The lack of documentation meant that staff were unaware of the resident's preference, and the resident continued to receive less healthy snack options. Resident 81's dietary preferences and allergies were not properly documented or respected. The resident's preference to avoid beans was not noted on the diet card, and the resident's shrimp allergy was not listed, posing a risk of an allergic reaction. The RD and Dietary Supervisor acknowledged the importance of documenting allergies and preferences to prevent exposure to allergens and ensure residents' dietary needs are met. The facility's policies on food allergies and tray card systems were not adhered to, leading to these deficiencies.
Failure to Provide Snacks as Requested
Penalty
Summary
The facility failed to adhere to its Nourishment Policy by not providing snacks to two residents, Resident 56 and Resident 81, as requested. Resident 56, who was diagnosed with schizoaffective disorder, alcohol dependence, and nicotine dependence, reported that when he asked for snacks, the nurses did not provide them. The facility's policy allowed for snacks at specific times, and additional snacks required approval from the Registered Dietician (RD) after an assessment. However, Resident 56 was not on the list to receive snacks at 10 a.m. and 8 p.m., and the RD stated that additional snacks would not be provided until she assessed the resident, which did not occur promptly. Similarly, Resident 81, who also had schizoaffective disorder and was under the care of a public guardian, expressed that snacks were important to him, yet he was not provided with them when requested. The Director of Nursing (DON) acknowledged that residents should be given snacks when requested, and withholding them could lead to hunger and weight loss. The facility's policy indicated that snacks should be available to residents outside of scheduled times, but this was not followed, leading to the deficiency.
Failure to Provide Arbitration Agreement in Language Understood by Conservator
Penalty
Summary
The facility failed to ensure that the conservator of a resident understood the Arbitration Agreement in a language they comprehended. Resident 21, who was admitted with diagnoses including schizoaffective disorder, alcohol dependence, and nicotine dependence, had a conservator responsible for making decisions on their behalf. The conservator's primary language was Spanish, but the Arbitration Agreement was provided in English, which the conservator did not fully understand. During interviews, it was revealed that the facility only offered the Arbitration Agreement in English, and although a translator explained the agreement in Spanish, the conservator could not refer back to the document in their primary language. This resulted in the conservator not having a full understanding of the binding nature of the Arbitration Agreement, as they were unable to explain what arbitration was.
Failure to Report COVID-19 Outbreak and Implement Mitigation Plan
Penalty
Summary
The facility failed to report 24 COVID-19 positive residents to the California Department of Public Health (CDPH) as required by the All Facilities Letter 23-08. This letter mandates the reporting of outbreaks and unusual infectious disease occurrences to the local public health officer and CDPH. The failure to report these cases resulted in a delay in the investigation by CDPH, potentially increasing the spread of COVID-19 infections within the facility. Additionally, the facility did not implement its COVID-19 Facility Mitigation Management Plan, which required all Health Care Personnel (HCP) to be provided with and wear facemasks or N95 masks while working in the facility. Observations revealed that staff members, including an Activity Assistant and a Laundry Assistant, were not wearing their masks properly, which could contribute to the spread of infection among residents and staff. Interviews with the Infection Preventionist (IP) and a Public Health Nurse (PHN) highlighted a lack of awareness and understanding of the reporting requirements. The IP was unaware of the need to report the outbreak to the Licensing and Certification District Office, and the PHN confirmed that the outbreak was not reported until several days after the initial positive test results. The facility's policy and procedure document also outlined the requirement for daily reporting of COVID-19 data to CDPH, which was not adhered to in this instance.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a staff member and a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe, as outlined in their policy and procedure. The incident involved a resident with a history of schizoaffective disorder, nicotine dependence, and homelessness, who reported being hit, kicked, and kneed by staff after becoming agitated. The resident had the capacity to make themselves understood and was independent in activities of daily living. The delay in reporting the incident resulted in a delay in the investigation by CDPH, potentially placing the resident and others at risk for further abuse. The Director of Nursing (DON) acknowledged the failure to report the incident in a timely manner, citing issues with fax transmission attempts that were not completed. The facility's policy, as well as an All Facilities Letter, clearly stated the requirement to report such incidents within two hours. Despite attempts to send a fax report, the facility was unaware that the transmission had not gone through, leading to the deficiency in timely reporting. Interviews with the Registered Nurse and DON confirmed the expectation to report abuse immediately to ensure resident safety and compliance with regulations.
Failure in Safe Transfer Planning
Penalty
Summary
The facility failed to ensure safe planning for the transfer or discharge of a resident, resulting in a delayed discharge as requested by the resident and their family member. The resident, who was diagnosed with schizoaffective disorder bipolar type, tobacco dependence, and insomnia, was admitted to the facility and had the capacity to make self-understood decisions and was independent in activities of daily living. Despite discussions with the resident's conservator and the interdisciplinary team about a lateral transfer to another skilled nursing facility closer to the family member, there was no follow-up or documentation of the discharge planning process. Interviews with facility staff revealed that the case manager and social services director did not have updates or proof of communication with the Department of Mental Health (DMH) liaison regarding the referral package necessary for the transfer. The social services director mentioned that the referral package was sent via email, but there was no log or proof of this communication, as the staff member responsible for sending it no longer worked at the facility. The director of nursing acknowledged the lack of a process to document the discharge planning and the need for a system to track such communications. The facility's policy required all documentation concerning transfers or discharges to be recorded in the resident's medical record, which was not adhered to in this case.
Deficiencies in Documentation and Monitoring
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents, leading to several deficiencies. For Resident 2, the staff did not document one-to-one monitoring at 10 PM on a specific date, despite the resident being on close supervision due to aggressive behavior. This lack of documentation was confirmed during interviews with a CNA and the Director of Nursing (DON), who acknowledged the incomplete documentation and its potential safety hazards. Additionally, the facility's policy required documentation of all interventions and their effectiveness, which was not adhered to in this case. Furthermore, the staff documented identical assessments for Resident 2 over different time periods, which was deemed inappropriate by both the DON and a Registered Nurse Supervisor (RNS). They emphasized the importance of accurate documentation to reflect the resident's true condition and to identify any concerns. The repeated documentation of the same assessment negatively impacted the quality of care provided to the resident. For Resident 1, the staff also documented the same assessments over different time periods and failed to update vital signs after a change in condition. The DON stated that vital signs should be taken after assessing residents and updated in their charts to notify the medical doctor if there were any changes. The facility's policies on charting, documentation, and monitoring of vital signs were not followed, leading to a delay in necessary treatments and potentially affecting the residents' quality of care.
Failure to Implement Care Plans After Resident Altercation
Penalty
Summary
The facility failed to implement the care plans for two residents following a physical altercation. Resident 1, who has schizoaffective disorder and other health conditions, was involved in an incident where he was hit on the shoulder by another resident. Despite having a care plan that required monitoring for shoulder swelling, there was no documented assessment of Resident 1's shoulder area. The Registered Nurse Supervisor confirmed that monitoring should have been documented in the progress notes, and the absence of documentation indicated that monitoring was not performed. Resident 2, who also has schizoaffective disorder and a history of stimulant and nicotine dependence, was the aggressor in the altercation. His care plan included interventions such as administering PRN medications and monitoring for side effects and effectiveness, as well as assessing his hand or fist for swelling. However, there was no documentation of monitoring for the side effects of the medication Zyprexa or assessment of his hand or fist area. Additionally, the 1:1 monitoring sheet for Resident 2 was incomplete, lacking documentation at a specific time. The Director of Nursing acknowledged the lack of documentation for both residents, emphasizing that all interventions should be documented even if no issues were observed. The facility's policy requires comprehensive care plans to prevent or reduce declines in residents' functional status, but the failure to document and implement the care plans for these residents indicates a deficiency in meeting this standard.
Failure to Notify Physician of Resident's Behavioral Change
Penalty
Summary
The facility failed to notify the physician when a resident exhibited inappropriate sexual behavior in a public setting. Specifically, the resident was observed masturbating in the doorway of his room, which was a public area. Despite this significant change in behavior, there was no notification made to the physician, psychiatrist, or psychologist, as required by the facility's procedures. The registered nurse acknowledged that a change of condition note should have been completed to inform the relevant medical professionals, allowing them to implement appropriate interventions. The Director of Nursing confirmed that the social services designee did not communicate the resident's behavioral change to the licensed nursing staff, which resulted in a delay in care. The facility's policy mandates prompt notification of any changes in a resident's medical or mental condition to the attending physician and responsible parties. The social services designee's job description also emphasizes the importance of timely and accurate communication with medical and nursing staff. This lapse in communication and procedure adherence led to a delay in addressing the resident's hypersexual behaviors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident with a known history of hypersexual behaviors. The incident involved Resident 1, who was observed masturbating in close proximity to Resident 2 in a public hallway. Despite the presence of staff, including a Registered Nurse and a Certified Nursing Assistant, no immediate intervention was made to separate the two residents, allowing the inappropriate behavior to continue. This lack of action resulted in Resident 2 experiencing feelings of anger and discomfort. Resident 1 had a documented history of hypersexual behavior, as noted in their care plan and behavior plan. The care plan included interventions such as attending group sessions for healthy relationships and impulse control, and staff were instructed to notify medical professionals for additional support. However, the facility failed to implement these interventions effectively, as evidenced by the repeated incidents of inappropriate behavior in public settings. Additionally, there was a failure to communicate changes in Resident 1's condition to the necessary medical staff, which could have led to timely adjustments in their care plan. The facility's policies and procedures for preventing resident abuse and monitoring high-risk behaviors were not adequately followed. Staff did not maintain a safe environment for Resident 2, nor did they respond appropriately to Resident 1's unsafe behavior. The Social Services Designee also failed to communicate critical information about Resident 1's behavior to the nursing staff, resulting in a delay in necessary medical interventions. This series of inactions and communication breakdowns contributed to the deficiency in ensuring resident safety and preventing abuse.
Failure to Implement Care Plan for Resident with Hypersexual Behavior
Penalty
Summary
The facility failed to effectively implement care plan interventions for a resident with hypersexual behaviors, leading to inappropriate conduct in a public setting. The resident, diagnosed with schizophrenia and COPD, was observed on camera footage standing close to another resident while engaging in inappropriate self-touching. Despite the presence of nursing staff, no immediate intervention was taken to address the behavior or model appropriate conduct. The care plan for the resident included attending therapeutic group meetings for healthy relationships, symptom management, and impulse control, as well as modeling appropriate behaviors. However, documentation revealed that the resident was only encouraged to attend a healthy relationships group once, and there was no evidence of encouragement for other group sessions. Additionally, the facility failed to notify the resident's medical team following the initial incident of inappropriate behavior, which was a critical step outlined in the care plan. The lack of communication and documentation regarding the resident's behavior and the failure to implement the care plan interventions resulted in repeated incidents of inappropriate behavior. This oversight not only affected the resident involved but also caused distress to other residents who witnessed the behavior. The facility's policies on monitoring high-risk behaviors and ensuring resident safety were not adequately followed, contributing to the deficiency.
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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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