Visalia Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 1925 E. Houston Ave, Visalia, California 93292
- CMS Provider Number
- 055604
- Inspections on file
- 52
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Visalia Post Acute during CMS and state inspections, most recent first.
A resident evaluated by a vascular physician was suspected to have CVI and PAD and received new orders for a left leg arterial duplex and venous duplex to be done at the facility. Nursing documentation noted the new orders and indicated Social Services would follow up with scheduling, but the studies were never documented as ordered or completed. The ADON could not find evidence of follow-up, and the SSA reported she was not informed of the orders until about two months later, despite facility policy requiring immediate recording of treatment orders in the chart. This failure led to a delay in the resident’s ordered diagnostic treatment.
A resident with a history of left foot injury was observed with a swollen, crusty, and draining second toe, but there was no documented assessment, physician notification, or treatment initiated by nursing staff. Despite documentation of a healing scab a week prior, no follow-up or monitoring was recorded, and staff confirmed that required change of condition protocols were not followed.
A resident with wounds to the left foot and toe did not have their wounds reevaluated when treatment orders ended. Both the treatment nurse and DON confirmed that reevaluation and documentation were required, but no evidence of this was found in the records, and no relevant policy was provided.
A resident with a foot wound identified by a podiatrist did not receive a referral to the wound care physician as ordered. Nursing staff and the DON were unable to provide documentation of the referral or evidence that the wound care physician was notified, resulting in the wound going untreated. This was not in accordance with the facility's policy for providing foot care and treatment.
A resident with a care plan for skin breakdown was observed with a right arm wound showing green drainage. An LVN noticed the drainage, cleaned the wound, and applied antibiotic ointment but did not notify the physician of the change in condition, despite facility policy and confirmation from the ADON that notification was required.
A resident with a urinary tract infection did not receive a scheduled dose of IV ceftriaxone as ordered by the physician. Review of the MAR and interview with the ADON confirmed the dose was not administered or documented, despite facility policy requiring such documentation for IV medications.
A resident who was hospitalized for severe abdominal pain and later expressed a desire to return was not permitted readmission by the facility, despite having intact cognition and the facility's policy prioritizing such returns. The administrator and ADON confirmed the decision not to allow the resident back, resulting in an unnecessary hospital stay and a violation of the resident's rights.
A resident with cognitive impairment and requiring moderate to maximum assistance was discharged home alone via Uber, without notifying APS, despite staff concerns for safety. The resident left medications behind, and staff were unable to contact emergency contacts. The facility failed to provide a policy for reporting such safety concerns.
The facility failed to ensure that advance directives (ADs) were offered and completed for 20 out of 36 sampled residents. Interviews and record reviews revealed that many residents either did not have an AD on file, or their ADs were incomplete, lacking necessary documentation such as signatures, dates, or specific medical wishes. The facility's policy requires that residents be informed of their right to formulate an AD, but this was not adhered to, potentially impacting residents' healthcare decisions.
The facility failed to maintain sanitary conditions and ensure equipment was in good repair in the food service area. The dishmachine and ice machine lacked proper installation, and floor sink drains were unsanitary, with rust and standing water. Clean foodservice equipment was stored with debris, and staff did not follow proper cleaning procedures before sanitizing surfaces, contradicting facility policies and FDA guidelines.
The facility failed to follow infection control policies, with an LVN administering medications without gloves, inadequate infection surveillance by the IPN, improper storage of used toilet brushes by housekeeping staff, and incorrect handling of respiratory therapy equipment. These actions were contrary to the facility's established procedures, potentially leading to the spread of infections.
The facility failed to provide annual training on abuse, neglect, and exploitation to a significant portion of its staff, including CNAs, LVNs, DAs, and others. This deficiency was identified during a review of training records and confirmed by the Director of Staff Development, who acknowledged the lack of make-up sessions and documentation. The absence of training could lead to unawareness of abuse reporting requirements among staff.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of transfers and discharges of four residents to a local hospital, denying them access to advocacy for their rights and options. The Medical Records Director was responsible for the notifications but could not provide evidence of doing so. Additionally, there was a lack of documentation regarding the residents' orientation and preparation for transfer, contrary to the facility's policy.
The facility failed to follow its policy on Binding Arbitration Agreements for four residents. The Admission Director did not adequately explain the agreement to two residents, and did not document verbal acknowledgment of understanding from any of the four residents. This resulted in the residents not being fully informed of their rights in case of a dispute.
A facility failed to provide a functioning wall light in a resident's room, as observed when the light above the bed did not turn on and the string to operate it was detached. The DSD and MS were unaware of the issue, despite a maintenance worksheet indicating the problem was corrected earlier. The facility's policy requires maintaining equipment in a safe and operable manner, which was not followed.
The facility failed to provide written bed-hold information to two residents during their hospital transfers, as required by policy. This omission could create uncertainty about their return to the facility and previous rooms.
The facility failed to maintain accurate MDSRM documentation for two residents, leading to potential unmet care needs and inaccurate medical records. One resident was incorrectly marked as being on transmission-based precautions, while another was inaccurately noted to have a tracheostomy. These errors were confirmed through interviews and record reviews, highlighting a lapse in the facility's documentation practices.
The facility failed to provide Baseline Care Plan (BCP) summaries to three newly admitted residents within 48 hours, as required. The BCP summaries lacked documentation of being provided, and there were no signatures from the residents or their representatives to confirm receipt. This oversight was contrary to the facility's policy, which mandates that a written summary be given and documented in the medical records.
The facility failed to ensure that the MD reviewed and countersigned VOs for two residents. A resident with respiratory issues was sent to the hospital based on a verbal order, but the signed order was missing from the chart. Similarly, another resident's chart lacked a signed VO for hospital transfer. The facility's policy requires practitioners to review and countersign VOs during their next visit, which was not followed.
A resident was found in a state of neglect, wearing a hospital gown with uncombed hair, long facial hair, and dirty fingernails. The resident expressed the need for grooming, and a nurse confirmed the lack of personal care provided. The facility's policy on Activities of Daily Living (ADL) was not followed, as the resident did not receive necessary care to maintain personal hygiene.
A facility failed to provide necessary care for a hospice resident with leg edema. Despite observations of pitting edema by the Hospice Nurse and RN, the condition was not documented in Weekly Nursing Assessments, and no treatment orders were provided by the MD after notification. This resulted in the resident not receiving required treatment for the swelling.
A facility failed to ensure proper communication and food safety for a resident receiving dialysis. The resident, with moderate cognitive impairment, was provided a paper bag lunch that was not consumed until hours later, risking foodborne illness due to inadequate temperature control. The facility's RD was unaware of the resident's eating habits, and the dialysis center did not allow food consumption during treatment. Documentation and communication between the facility and dialysis center were insufficient, leading to a deficiency in care.
A facility failed to provide routine dental services to a resident, as a dental referral indicated in the resident's Order Summary was missed. The resident was observed without teeth, and the facility's policy on Resident Rights was not followed, potentially leading to unnoticed dental issues.
A resident did not receive their prescribed therapeutic diet when drinks were left out for hours and a meal tray was missing a nectar-thick punch. The resident, who was non-verbal and had physical limitations, was unable to access the drinks independently. The facility's dietary manager confirmed the oversight, highlighting a failure to adhere to the therapeutic diet policy.
The facility failed to honor the food preferences of two residents, leading to an unpleasant dining experience. A resident was served chili beans despite disliking them, and another received a meal with tomatoes, which they disliked. Additionally, a resident with lactose intolerance was served dairy-based hot chocolate, contrary to a doctor's order. The facility also did not ensure a resident was aware of the menu in time to request an alternative meal.
The facility did not meet the required square footage for 11 rooms, with some rooms housing three residents in spaces below the 80 square feet per resident standard. Despite this, the facility maintained that the rooms were adequate for residents' needs, and no complaints were reported by the residents.
A resident's call light was found on the floor, out of reach, preventing the resident from calling for assistance. Staff interviews confirmed the oversight, and the facility's policy requires call lights to be accessible to residents.
The facility failed to report a scabies outbreak to the state health department, as required by its policy. Three residents were clinically diagnosed with scabies, but the outbreak was only reported to the local health department. The facility's policy mandates reporting to both local and state health departments for communicable diseases, which was not followed in this case.
A resident with confusion and behavioral issues was not referred to a psychiatrist despite recommendations from the interdisciplinary team and agreement from the primary doctor. The facility lacked a psychiatrist, and the referral was not made, contrary to the facility's policy.
The facility failed to provide a homelike environment for a resident when the bed linen was found to have a hole and discolored areas due to thinning. Both a CNA and an LVN confirmed the condition, and the DON acknowledged that such linen should not have been used, as per facility policy.
A facility failed to report an abuse allegation when a family member informed an LVN that a resident claimed a male staff member hit her. Despite knowing about the allegation for two weeks, the LVN did not report it, violating the facility's policy requiring immediate reporting of abuse suspicions.
The facility failed to provide podiatry services for two residents, resulting in long, jagged, and discolored toenails. Observations and interviews revealed that the facility staff relied on podiatry services for toenail care, but there was no evidence that the residents had received the necessary care.
A resident with a history of gastric bypass surgery experienced ongoing abdominal pain and nausea, leading to a small bowel obstruction diagnosis. Despite multiple episodes of nausea and vomiting, the facility failed to notify the physician promptly, resulting in a delay of care. The Director of Nursing acknowledged the oversight, which was against the facility's policy requiring timely physician notification for significant changes in condition.
A facility failed to document and potentially provide prescribed wound care for a resident with multiple ulcers, as indicated by blank entries in the Treatment Administration Record (TAR) on several dates. The resident required daily monitoring and treatment for a diabetic ulcer, a stage 3 pressure ulcer, and a deep tissue injury. The Assistant Director of Nursing confirmed the lack of documentation, which was against the facility's wound care policy.
A facility failed to ensure complete documentation of a resident's bowel movements, resulting in incomplete records. The Director of Nursing acknowledged the lack of documentation for certain dates and the absence of consistency and size details. The Director of Staff Development confirmed her responsibility for training staff on proper documentation, which should include whether the resident was continent or incontinent, as well as the consistency and size of the bowel movements. The facility's Bowel Management Protocol requires CNAs to document these details on the resident flow record.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the dementia unit due to staff failing to respond promptly to a security door alarm and a malfunctioning service gate. The resident was found a quarter of a mile away from the facility.
Failure to Follow Up on Vascular Diagnostic Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow up on physician orders for diagnostic vascular studies for one resident. A vascular physician documented in a progress note that the resident was suspected to have both chronic venous insufficiency (CVI) and peripheral arterial disease (PAD) and ordered left leg arterial and venous duplex studies to be done at the facility. A subsequent nursing progress note the same day documented that the resident had returned from the vascular appointment with new orders from the vascular MD for a left leg arterial duplex and a left leg venous duplex, and that Social Services would follow up with appointments for these procedures. During surveyor review with the Assistant Director of Nursing, there was no documentation that the ordered arterial and venous duplex studies had been followed up on or completed, and the ADON acknowledged that the orders should have been entered on the physician orders and followed up. The Social Service Assistant stated that when a resident has an order for treatment outside the facility, the nurse is supposed to provide her a copy of the order so she can arrange the appointment and transportation, but she was not made aware of this resident’s orders until approximately two months after they were written. The facility’s policy on Medication and Treatment Orders required that verbal orders be recorded immediately in the resident’s chart with specific details, but the documentation and follow-up process for these ordered studies did not occur as required, resulting in a delay of treatment.
Failure to Assess, Notify Physician, and Treat Change in Condition for Resident's Foot Injury
Penalty
Summary
The facility failed to assess, notify the physician, and treat a change in condition for a resident who presented with a swollen left foot, drainage, and dry, crusty debris covering the second toe and nail bed. Observation revealed the resident's left foot was swollen, with debris between the toes and a dried scab on the inside of the foot. The second toenail bed and top of the toe were covered with lumpy, yellow, crusty debris. A review of the resident's Shower/Bed Bath Sheet from seven days prior indicated a healing scab on the left foot, but there was no documented response or follow-up action by the licensed nurse, despite the form prompting for such action. During further evaluation, an LVN noted the second toe was swollen, dry, had drainage, and appeared infected, with no current treatments being administered. The CNA reported the resident had a history of injuring her left foot during a transfer, and the second toe had looked like a cauliflower since the initial injury. The LVN and DON both confirmed that a change of condition should have been completed, the physician notified, and new orders implemented when the skin issue was identified, but there was no evidence of ongoing treatment or monitoring. The facility's policy required physician notification and intervention for significant changes in a resident's condition, which was not followed in this case.
Failure to Reevaluate Wounds at End of Treatment Orders
Penalty
Summary
The facility failed to reevaluate wounds for a resident when treatment orders were ending. According to progress notes, the resident returned from a hospital appointment with a bleeding left second toe, where the nail was not intact, and a skin tear on the left lateral foot. Orders were given to cleanse and treat both wounds with bacitracin every shift, monitor for infection and worsening for 14 days, and follow up with a wound doctor. The Treatment Administration Record showed that the last day of treatment and monitoring for these wounds was on 7/6/25 during the day shift. Interviews with the treatment nurse and the Director of Nursing confirmed that wounds should have been reevaluated at the end of the treatment period, with documentation in the progress notes indicating whether treatment should continue or be discontinued. However, neither staff member could provide documentation that the wounds were reevaluated at the end of the treatment period. Additionally, the facility was unable to provide a policy regarding wound reevaluation at the end of treatment orders.
Failure to Refer Resident for Wound Care as Ordered by Podiatrist
Penalty
Summary
The facility failed to follow physician orders regarding foot care for one resident who had a wound on the left dorsal forefoot, as identified during a podiatry evaluation. The podiatrist documented the presence of a 3x3 cm wound, applied a dressing, notified nursing staff, and instructed that wound management be deferred to the wound care physician. The podiatrist also indicated that if further recommendations were needed from a podiatry standpoint, a specific reconsult should be requested. Despite these instructions, there was no documentation that the resident was referred to the wound care physician as ordered. Both the treatment nurse and the DON confirmed during interviews and record reviews that they could not provide evidence of a referral or that the wound care physician had been notified. The facility's policy requires that residents receive foot care and treatment in accordance with professional standards, including the management of medical conditions to prevent complications, but this was not followed in this instance.
Failure to Notify Physician of Wound Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician of a change in condition for a resident whose wound worsened. The resident, identified as being at risk for skin breakdown, had a care plan that required staff to check skin during daily care and notify the physician of abnormal findings. On observation, the resident was found with steri-strips on her right arm near the elbow, with green drainage visible on the wound, which is often a sign of infection. A Licensed Vocational Nurse (LVN) reported noticing green drainage from the resident's wound the previous day, cleaned the wound, applied triple antibiotic ointment, and left it uncovered, but did not notify the physician of this change. The LVN confirmed that the physician should have been notified. The Assistant Director of Nursing also stated that the physician should have been informed when green drainage was observed. Facility policy required nurses to notify the attending physician of significant changes in a resident's condition and to document such changes in the medical record.
Missed IV Antibiotic Dose Due to Failure to Follow Physician's Order
Penalty
Summary
The facility failed to follow a physician's order for a resident who was prescribed intravenous ceftriaxone to treat a urinary tract infection. The physician's order specified that the antibiotic was to be administered once daily for seven days. Review of the resident's care plan confirmed the need for medication administration as ordered. However, documentation on the Medication Administration Record showed that the ceftriaxone dose was not given on one of the scheduled days, and the Assistant Director of Nursing was unable to provide evidence that the medication was administered. Facility policy required documentation of all IV medication administration, including date, time, and clinician initials, but this was not completed for the missed dose.
Failure to Permit Resident Readmission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, despite the resident expressing a desire to return and the facility's own policy stating that residents discharged to the hospital or on therapeutic leave would be given priority readmission. The resident, who had intact cognition as indicated by a BIMS score of 14, was initially transferred to the hospital due to severe abdominal pain. After her condition improved, both the hospital social worker and the resident herself communicated with the facility regarding her return. The administrator and assistant director of nursing confirmed that the facility would not allow the resident to return, citing a lack of available beds and later stating that the resident would not be permitted to return even if a bed became available. This action resulted in the resident remaining unnecessarily in the hospital and violated the facility's stated policy and the resident's rights.
Failure to Notify APS for Resident Discharge with Safety Concerns
Penalty
Summary
The facility failed to notify adult protective services (APS) when a resident was discharged home alone, despite staff concerns about the resident's cognitive status and safety. The discharge summary indicated that the resident required moderate to maximum assistance with activities such as bed mobility, transfer, dressing, bathing, grooming, hygiene, and toilet use. The resident was also incontinent of both bladder and bowel. The care plan noted cognitive impairment, with interventions to anticipate needs and provide memory cues. On the day of discharge, the resident was sent home via Uber without any accompanying person, and medications were left behind as the discharge was uncertain until shortly before the ride arrived. Interviews with facility staff revealed that the resident was confused on the day of discharge, and attempts to contact the resident's emergency contacts were unsuccessful. The Licensed Vocational Nurse (LVN) expressed concern about discharging the resident without anyone knowing, and the Assistant Director of Nursing (ADON) confirmed that the resident had episodes of confusion during their stay. The Social Service Director (SSD) stated that safety concerns should have been reported to APS, but no facility policy was provided to support this procedure.
Failure to Ensure Completion of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were offered and completed for 20 out of 36 sampled residents. This deficiency was identified through interviews and record reviews conducted with the Social Services Assistant (SSA) and the Medical Records Director (MRD). The review revealed that many residents either did not have an AD on file, or their ADs were incomplete, lacking necessary documentation such as signatures, dates, or specific medical wishes. During the interviews, the SSA and MRD were unable to provide documentation of ADs for several residents, including Residents 113, 73, 411, 128, 104, 135, 2, 111, 77, 312, 311, 81, 51, 68, 313, 36, 101, 43, 109, and 84. In many cases, the AD forms were found to be blank or incomplete, with missing acknowledgments or signatures. The SSA acknowledged these deficiencies, noting that some residents' ADs were not transferred correctly during a system change from matrix charting to point-click-care charting. The facility's policy and procedure on advance directives, dated 2001, requires that residents be informed of their right to formulate an AD and that the existence of any ADs be determined upon admission. However, the facility failed to adhere to this policy, as evidenced by the lack of completed ADs for the majority of the sampled residents. This failure had the potential to result in residents' healthcare wishes not being honored, as there was no documentation to guide medical decisions in the event that residents became incapacitated.
Sanitation and Equipment Maintenance Deficiencies in Food Service Area
Penalty
Summary
The facility failed to maintain sanitary conditions and ensure equipment was in good repair in the food service area, as observed during a survey. The dishmachine and ice machine were not installed according to the manufacturer's guidelines, lacking a visible floor drain and proper air gap to prevent backflow of potentially contaminated water. The Maintenance Supervisor was unaware of these requirements, and the Certified Dietary Manager confirmed the absence of a drain or air gap for the new ice machine. This non-compliance with the facility's policies and the FDA Food Code posed a risk of contamination. Additionally, the facility did not maintain floor sink drains in a sanitary manner. Observations revealed that the floor sink drain under a foodservice steamer was covered in an orange-colored substance, identified as rust, and had missing or cracked portions, preventing adequate cleaning. Another floor sink drain was full of standing water, which frequently overflowed onto the kitchen floor, creating unsanitary conditions. The Certified Dietary Manager acknowledged these issues, and the Maintenance Supervisor admitted the need for further investigation to identify the problem. The facility also failed to properly clean and sanitize food contact surfaces. Clean foodservice equipment was stored on shelves with scattered dried food debris, and staff used a sanitizing solution without prior cleaning with detergent. The Certified Dietary Manager admitted to not incorporating a wash with detergent step before sanitizing, believing that sanitizing alone was sufficient. This practice contradicted the facility's policies and the FDA Food Code, which require cleaning to remove organic matter before sanitization to prevent contamination.
Infection Control Deficiencies in Medication Administration and Housekeeping
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures in several instances. A Licensed Vocational Nurse (LVN) was observed administering medications to two residents without using gloves, directly touching the pills with ungloved hands. This action was contrary to the facility's policy on administering medications, which requires staff to follow infection control procedures, including the use of gloves. The Director of Nursing confirmed that the pills should not be touched by hand and should be placed directly into the pill cup. The Infection Preventionist (IPN) did not conduct adequate surveillance activities as per the facility's infection control policies. The IPN was responsible for monitoring hand hygiene and other infection control practices but failed to document the time of surveillance, actions taken to correct non-compliance, or any analysis of the data collected. The adherence rates for hand hygiene were low, ranging from 65% to 75%, and there was no record of corrective actions or education provided to staff to address these deficiencies. Additionally, the facility's housekeeping staff did not follow proper procedures for storing cleaning equipment. Used toilet brushes were found stored alongside clean supplies such as unopened boxes of gloves on housekeeping carts. This improper storage practice was acknowledged by the housekeeping staff and the Infection Prevention Nurse Consultant, who confirmed that used toilet brushes should not be stored with clean supplies. Furthermore, respiratory therapy equipment for a resident was not labeled or stored correctly, with tubing not being replaced as required by the facility's policy, which mandates changing the tubing every seven days.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program by not providing annual training to a significant portion of its staff. Specifically, 17 out of 73 Certified Nursing Assistants (CNAs), 7 out of 31 Licensed Vocational Nurses (LVNs), 4 out of 12 Dietary Aids (DAs), 2 out of 4 cooks, 2 out of 20 Feeding Assistants (FAs), 1 out of 3 Speech Language Pathologists (SLPs), 1 out of 2 Respiratory Therapists (RTs), 1 out of 6 Restorative Nursing Assistants (RNAs), 2 out of 3 Occupational Therapists (OTs), 1 Minimum Data Set Coordinator (MDSC), and 1 out of 7 Registered Nurses (RNs) did not receive the required training. This lack of training was confirmed during an interview and record review with the Director of Staff Development, who acknowledged that the staff had not attended make-up sessions and no additional documentation was provided. The absence of documented training for these staff members indicates a failure to ensure that they are aware of what constitutes abuse, neglect, and exploitation, as well as the reporting requirements. This deficiency was identified during a review of the facility's annual training records and its policy and procedure document dated April 2021, which mandates staff orientation and training. The failure to provide this essential training had the potential for abuse in residents to go unnoticed and unreported within the facility.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide the Office of the State Long-Term Care Ombudsman (OSLTCO) with a Notice of Transfer for three residents who were transferred to a local hospital and one resident who was discharged to a hospital. This failure resulted in the residents not having immediate access to an advocate who could inform them of their transfer or discharge options and rights. The Medical Records Director (MRD) was responsible for notifying the Ombudsman but was unable to provide evidence of notification or confirmation of receipt from the Ombudsman's office. In the case of Resident 51, the Assistant Director of Nursing (ADON) and the Social Services Director (SSD) were involved in the transfer process, but there was no documentation of the notification to the Ombudsman or evidence of nursing documentation in the Nursing Progress Notes regarding the resident's orientation and preparation for transfer. Similarly, for Resident 68, there was no record of notification to the Ombudsman, and the ADON could not find documentation of the resident's orientation and preparation for transfer. Resident 127 was transferred to the hospital due to respiratory issues, but the MRD was not aware of the requirement to notify the Ombudsman for hospital transfers. Resident 159 was discharged to a hospital for a CT scan, and again, there was no notification to the Ombudsman. The facility's policy and procedure indicated that notice of transfer should be provided to the resident and representative as soon as practicable and to the LTC Ombudsman when practicable, but this was not followed in these cases.
Failure to Properly Explain and Document Binding Arbitration Agreement
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Binding Arbitration Agreement (BAA) for four sampled residents. The Admission Director (AD) did not explain the BAA to two residents in a manner they could understand before they signed the agreement. Specifically, Resident 62 and Resident 134 were not adequately informed about the BAA, with Resident 62 not understanding the form and Resident 134 not recalling the signing or explanation of the form. The BIMS scores for these residents were 12 and 15, respectively, indicating moderate cognitive impairment for Resident 62 and intact cognition for Resident 134. Additionally, the AD did not document a verbal acknowledgment of understanding the BAA from any of the four residents, including Residents 62, 134, 101, and 135. The facility's policy requires that the terms and conditions of the BAA be explained to the resident or their representative, ensuring their understanding, and that a verbal acknowledgment of understanding be documented. However, the AD only obtained signatures from the residents without documenting their acknowledgment or understanding, which resulted in the residents not being fully aware of their rights in case of a dispute with the facility.
Failure to Maintain Functioning Wall Light in Resident's Room
Penalty
Summary
The facility failed to ensure a functioning wall light was provided in a resident's room, specifically for Resident 139. During an observation, it was noted that the light above the resident's bed did not turn on, and the string to operate the light was detached. The Director of Staff Development (DSD) was unaware of the issue until it was pointed out during the observation. The Maintenance Supervisor (MS) also stated he was not aware of the broken light, although the facility's Departmental Maintenance Worksheet indicated that the light chord was broken and was supposedly corrected two days prior. The facility's policy and procedure for maintenance service requires the maintenance department to maintain equipment in a safe and operable manner at all times, which was not adhered to in this instance.
Failure to Provide Written Bed-Hold Information
Penalty
Summary
The facility failed to provide written information on bed-hold policies to two residents, Resident 51 and Resident 68, during their transfers to an acute care hospital. The Admissions Director stated that the facility's admission packet included a form discussing bed-hold upon admission, and that nurses should inform residents or their representatives about bed-hold before a transfer. However, during a review of Resident 51's medical record, it was found that there was no evidence that written information about bed-hold was provided when the resident was transferred to a hospital on June 24, 2024. Similarly, Resident 68 was transferred to a hospital on January 25, 2025, for evaluation and treatment of a scalp laceration after a fall, but there was no evidence that the resident or their representative received written information about bed-hold. The facility's policy and procedure on bed-holds and returns indicated that residents should receive written notice about bed-hold policies at least twice: in the admission packet and at the time of transfer, or within 24 hours if the transfer was an emergency. The failure to provide this information had the potential to create uncertainty for the residents regarding their ability to return to the facility and their previous rooms.
Inaccurate MDSRM Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and timeliness of the Minimum Data Set Resident Matrix (MDSRM) for two residents, leading to potential unmet care needs and inaccurate medical records. For Resident 135, the MDSRM inaccurately indicated that the resident was on transmission-based precautions (TBP), despite interviews with the Licensed Vocational Nurse (LVN) and the Minimum Data Set Coordinator (MDSC) confirming that the resident had not been on TBP since October 2024. Additionally, the MDS sections reviewed did not reflect any respiratory therapy or issues with shortness of breath, further highlighting the inaccuracy in the resident's assessment. Similarly, for Resident 152, the MDSRM incorrectly marked the presence of a tracheostomy, even though observations and record reviews confirmed that tracheostomy care had been discontinued since December 17, 2024. The MDSC admitted to not updating the matrix to reflect this change, despite the facility's policy requiring complete and accurate documentation. These inaccuracies in the MDSRM could lead to potential care discrepancies and misinformed medical decisions for the residents involved.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a Baseline Care Plan (BCP) summary to three newly admitted residents within the required 48-hour timeframe. During interviews and record reviews, it was found that the BCP summaries for Residents 311, 312, and 313 were incomplete. Specifically, the section indicating that a printed BCP summary was provided was left blank, and there were no signatures from the residents or their representatives to confirm receipt of the BCP summaries. The Assistant Director of Nursing (ADON) was unable to provide documented evidence that the BCPs were given to the residents or their representatives. The facility's policy and procedure on Baseline Care Plans, dated March 2022, requires that a written summary of the BCP be provided to the resident or their representative in a language they understand, and that this provision be documented in the medical records. However, this policy was not followed for the three residents in question, as evidenced by the lack of documentation and confirmation of receipt. This oversight had the potential to impact the care and safeguards necessary for the residents within the first 48 hours of their admission.
Failure to Countersign Verbal Orders for Two Residents
Penalty
Summary
The facility failed to ensure that the Medical Doctor (MD) reviewed and countersigned verbal orders (VO) for two residents, Resident 101 and Resident 127. For Resident 127, a Licensed Vocational Nurse (LVN) noted crackles in the right lung and diminished breath sounds in the left lung, indicating difficulty breathing. The resident was on oxygen at 3 liters, and the MD gave a verbal order to send the resident to the hospital. However, the signed VO was not found in the resident's chart. Similarly, for Resident 101, the Minimum Data Set Coordinator (MDSC) acknowledged that a VO should have been given for the resident to be sent to the hospital, but the signed VO was missing from the resident's chart. The facility's policy requires practitioners to review and countersign verbal orders during their next visit, which was not adhered to in these cases.
Failure to Provide ADL Support for a Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for Activities of Daily Living (ADL) for one of the sampled residents, identified as Resident 81. During an observation, Resident 81 was found sitting on his bed wearing a hospital gown, with uncombed long hair, and long facial hair. His fingernails were long and contained a blackish substance. Resident 81 expressed the need for grooming, including shaving and nail trimming, and was waiting for a Certified Nursing Assistant (CNA) to assist. A Registered Nurse (RN) confirmed that Resident 81 had not been showered, combed, or changed, and acknowledged the need for shaving and nail trimming. A CNA noted that Resident 81 frequently scratched his legs and private area, leading to dirty fingernails. The facility's policy indicated that residents should receive care to maintain or improve their ability to perform ADLs, which was not followed in this instance.
Failure to Address Edema in Hospice Resident
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident in hospice care who was experiencing edema in both legs. Weekly Nursing Assessments did not document the presence of edema, despite observations of pitting edema by the Hospice Nurse and Registered Nurse. The Hospice Nurse had notified the Medical Doctor about the condition, but no treatment orders were provided. This lack of documentation and follow-up resulted in the resident not receiving necessary services and treatment for the swelling in her legs. The Assistant Director of Nursing and Nursing Consultant reviewed the resident's Physician's Progress Notes and found no documentation addressing the pitting edema since the initial notification to the physician. The facility's policies and procedures require that changes in a resident's condition be documented and communicated to ensure quality care, but these protocols were not followed in this case. The failure to document and address the resident's edema represents a deficiency in the care provided by the facility.
Inadequate Communication and Food Safety for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication between its Registered Dietitian (RD) and the RD at the dialysis center regarding the safe provision of lunch for a resident who required dialysis three times a week. The resident, who had moderate cognitive impairment, was provided with a paper bag lunch containing a turkey or tuna sandwich, which was not consumed until six to seven hours later, potentially placing the food in the temperature danger zone. The facility's RD was unaware that the resident did not eat at the dialysis center and usually ate upon returning to the facility, which could lead to foodborne illness due to inadequate time/temperature control. Interviews revealed that the resident left the facility with a packed lunch but often did not consume it until returning from dialysis. The Certified Dietary Manager confirmed the contents of the lunch, which included a sandwich, apple sauce, a fresh apple, crackers, and cookies, but no fluids. The RD at the dialysis center stated that residents were not allowed to eat during dialysis for infection control purposes, and there was no provision for storing food at the center. The resident sometimes ate in the lobby after dialysis, but this was not consistently documented or communicated between the facility and the dialysis center. The facility's documentation and communication processes were insufficient, as there were no fields on the forms to document whether the resident arrived with a lunch or consumed it at the dialysis center. The facility's best practice workflow for dialysis communication emphasized the need for ongoing coordination between the nursing home and dialysis staff, but this was not effectively implemented. The lack of proper documentation and communication regarding the resident's meal consumption and storage led to a deficiency in providing safe and appropriate dialysis care services.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to one of the six sampled residents, identified as Resident 106. During an observation in Resident 106's room, it was noted that the resident did not have teeth. A subsequent interview and record review with the Social Services Assistant revealed that a dental referral for Resident 106, which was indicated in the Order Summary dated June 1, 2024, was missed. The facility's policy and procedure on Resident Rights, dated September 2009, states that residents have the right to choose a physician and treatment and participate in decisions and care planning. This oversight had the potential for poor eating and unnoticed dental issues such as broken or loose teeth.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident, identified as Resident 311, which led to deficiencies in meeting the resident's nutritional needs. On one occasion, two sippy cups containing nectar-thick liquids were left on the resident's nightstand from 8 a.m. until 12:54 p.m., rendering the drinks out-of-range in temperature and unsuitable for consumption. The resident, who was non-verbal, had no teeth, and a contracted left hand, was unable to access the drinks independently. When a CNA noticed the drinks, they were given to the resident, who drank quickly, indicating thirst. The Certified Dietary Manager confirmed that the drinks should not have been left at the bedside and were not suitable for consumption after sitting out for such an extended period. Additionally, the resident's lunch tray was missing an 8-ounce nectar-thick punch drink, which was part of the prescribed therapeutic diet. The Licensed Vocational Nurse delivering the tray confirmed the absence of the drink, and the Certified Dietary Manager acknowledged that the drink was missed in the kitchen and the tray was not properly checked before delivery. The facility's policy on therapeutic diets emphasizes the importance of adhering to physician-ordered diets to support treatment and care plans, which was not followed in this instance.
Failure to Honor Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor the food preferences of two residents, resulting in an unpleasant dining experience. Resident 28 was served chili beans despite having a standing order for chicken noodle soup and a documented dislike for beans. The Certified Dietary Manager (CDM) acknowledged the oversight, confirming that the meal tray did not comply with Resident 28's meal ticket instructions. Additionally, Resident 51 was served a meal containing tomatoes, which was listed as a disliked item on their meal ticket. The CDM admitted to making a mistake by serving the three-bean chili, which included tomatoes, despite being aware of Resident 51's aversion to tomato products. The facility also failed to ensure that Resident 51 was aware of the menu in time to request an alternative meal. Resident 51, who is bed-bound and has multiple medical issues, expressed confusion about the facility's rules for ordering alternate meals. The resident was unable to see the menu posted on the wall and was told that requests for alternative food items were not accepted if made too late. The CDM confirmed that there were specific times for ordering alternate food, requiring at least one hour's notice before lunch or dinner. Furthermore, the facility did not provide an alternative milk product for Resident 311, who has lactose intolerance. Despite a doctor's order to discontinue dairy-based nourishment, Resident 311 was served hot chocolate containing dairy. The CDM was aware of the oversight and acknowledged that the dietary staff had not been informed of the new orders in a timely manner. This failure to accommodate Resident 311's dietary needs was contrary to the facility's policy of providing alternative meals for personal food preferences or refusals.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum square footage as required by regulation for 11 out of 50 rooms. During observations, it was noted that rooms housing three residents did not meet the required 80 square feet per resident. Specifically, one room measured 227.2 square feet, another 219.2 square feet, and a third 234.5 square feet, all of which were below the required space for three residents. Despite the deficiency, the facility maintained that the rooms were adequate for the residents' needs, with sufficient closet and storage space, bed stands, and room for nursing care and ambulation. The Administrator and Maintenance Supervisor acknowledged the issue but noted that residents had not complained about the room sizes.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within easy reach, which is essential for the resident to alert staff for assistance. During an observation and interview, it was noted that the call light was on the floor and not accessible to the resident. The resident attempted to locate the call light by feeling around his bed but was unsuccessful. This situation was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the call light should always be within the resident's reach. Further interviews with staff, including a Licensed Vocational Nurse (LVN) and another CNA, confirmed that the call light was not placed within reach after the resident was laid back in bed. The Director of Nurses (DON) also stated that the call light should be placed within reach. The facility's policy and procedure on the call system indicated that residents should have a means to call staff for assistance, which was not adhered to in this instance.
Failure to Report Scabies Outbreak to State Health Department
Penalty
Summary
The facility failed to implement its policy and procedure regarding the reporting of a scabies outbreak to the state health department. This deficiency was identified during a review of records and interviews with staff members. Three residents were clinically diagnosed with scabies by the wound doctor on the same day. The facility's Infection Preventionist and Treatment Nurse confirmed these diagnoses. However, the Director of Nursing stated that while the outbreak was reported to the local health department, it was not reported to the state health department as required by the facility's policy. The facility's policy on communicable disease outbreaks defines an outbreak as one case of a highly communicable infection or three or more cases of the same infection within a specified period and area. The policy mandates that the administrator is responsible for communicating data about reportable diseases to the health department. Despite this, the facility did not adhere to its policy, resulting in the state health department being unaware of the scabies outbreak among the residents.
Failure to Refer Resident for Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure a psychiatrist referral was made for a resident, resulting in a delay of psychiatric evaluation. The resident, who was alert but confused and exhibited behaviors such as wandering and taking others' property, was seen by a psychologist who recommended considering the restart of Seroquel. However, the interdisciplinary team (IDT) did not agree with this recommendation and suggested a referral to a psychiatrist for further evaluation. The primary medical doctor agreed with the IDT's plan. Despite the IDT's recommendation and agreement from the primary doctor, the referral to a psychiatrist was not made. The Social Service Director (SSD) acknowledged that at the time of the recommendation, the facility did not have a psychiatrist available, and the resident was not referred externally. The Director of Nursing (DON) confirmed that the resident should have been referred to a psychiatrist. The facility's policy indicated that social services should coordinate referrals based on physician evaluation, but this was not documented in the resident's medical record.
Failure to Provide Homelike Environment Due to Damaged Bed Linen
Penalty
Summary
The facility failed to provide a homelike environment for one of three sampled residents when the bed linen was not in good repair. During an observation and interview, it was noted that the resident's bed sheet had a hole and two areas where the sheet was discolored due to thinning. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 both confirmed the condition of the sheet. The Director of Nursing (DON) stated that bed sheets with holes and discoloration should not have been used. The facility's policy and procedure indicated that torn linen should not be used to ensure a clean and comfortable bed for residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse for one of the sampled residents when a family member informed an LVN about the abuse. The family member reported that every time a male staff member walked by, the resident would say he hits her. Despite being aware of this allegation, the LVN did not report it to the management as required by the facility's policy. This failure was confirmed during interviews with the family member, the LVN, and other staff members, including the DON and the Social Service Director, who were unaware of any recent abuse allegations. The facility's policy mandates that any suspicion of abuse must be reported immediately, defined as within two hours of the allegation, but this protocol was not followed in this case. During the investigation, it was revealed that the LVN had been informed of the resident's distress and allegations approximately two weeks prior but failed to take the necessary steps to report it. The facility's policy and procedure document, reviewed during the investigation, clearly states that all reports of resident abuse must be reported to local, state, and federal agencies and thoroughly investigated by facility management. The DON confirmed that the staff member should have adhered to the policy and reported the allegation immediately. This lapse in protocol had the potential to delay the investigation and place other residents at risk for abuse.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide podiatry services for two residents, resulting in both having long, jagged, and discolored toenails. Resident 2 was observed walking in the hallway with open-toe sandals, revealing long and discolored toenails. A review of Resident 2's Order Summary Report indicated a need for podiatry consultation due to mycotic and hypertrophic nails, but there was no evidence that Resident 2 had received podiatry care. The Director of Nursing (DON) confirmed that the facility staff does not provide toenail care and relies on the podiatrist for such services. Resident 1 had a podiatry progress note indicating a follow-up was needed two months after August 2023, but there was no evidence of subsequent podiatry care. Shower sheets from April and May 2024 indicated that Resident 1's toenails needed clipping. During an observation, Resident 1 was found to have long, jagged toenails with debris underneath. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 both stated that podiatry services were responsible for toenail care. The Social Service Director (SSD) confirmed that nursing staff should report the need for podiatry services to social services, but Resident 1 had not been seen by podiatry since August 2023. The DON acknowledged that both residents needed podiatry services and that their toenails did not look good.
Delayed Physician Notification for Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician in a timely manner when a resident continued to experience a change in condition, resulting in a delay of care. The resident, who had a history of gastric bypass surgery, experienced abdominal pain and nausea, and was diagnosed with a small bowel obstruction. On 1/31, the resident had two episodes of vomiting and refused meals, prompting a call to the physician and new orders for immediate lab tests and an abdominal x-ray. However, despite the resident's ongoing symptoms, including multiple episodes of nausea and vomiting, the physician was not promptly informed of the continued issues. The resident's condition persisted over the next two days, with continued episodes of nausea and vomiting, and the medication provided was only temporarily effective. The physician was finally informed and gave new orders to send the resident out to rule out a small bowel obstruction. The Director of Nursing acknowledged that the physician should have been notified earlier when the medication was not effective. The facility's policy requires notifying the physician when there is a significant change in a resident's condition that requires altering medical treatment, which was not adhered to in this case.
Failure to Document and Provide Wound Care
Penalty
Summary
The facility failed to provide appropriate wound treatments for a resident, as evidenced by the review of the Treatment Administration Record (TAR) for January 2024. The TAR indicated that the resident required daily monitoring and treatment for a right heel diabetic ulcer, a stage 3 pressure ulcer on the right lower back, and a deep tissue injury (DTI) at the sacrococcygeal area. Specific treatments were prescribed, including the use of betadine swabs, normal saline, collagen fiber, medihoney manuka pads, and foam dressings. Additionally, heel/foot protectors and a low air loss mattress were to be used to promote skin integrity and prevent further injury. However, the TAR was found to be blank on several dates, indicating that the treatments were not documented as completed. During an interview and record review with the Assistant Director of Nursing (ADON), it was confirmed that the treatments were not documented on the specified dates. The facility's policy and procedure for wound care, dated October 2010, required that the type of wound care, date and time of care, and the name and title of the individual performing the care be recorded in the resident's medical record. The lack of documentation suggested that the prescribed wound care may not have been provided, potentially leading to a worsening of the resident's condition.
Incomplete Bowel Movement Documentation
Penalty
Summary
The facility failed to ensure complete documentation of bowel movements (BM) for a resident, resulting in incomplete records. During an interview and record review with the Director of Nursing (DON), it was found that the resident's BM Report was undated and lacked documentation for a specific date. Additionally, there was no documentation of the consistency or size of the BM on several other dates. The DON acknowledged that the BM documentation was incomplete and stated that the size and consistency should have been recorded. The Director of Staff Development (DSD) confirmed during an interview that she was responsible for training staff on BM documentation. She stated that staff should document whether the resident was continent or incontinent, as well as the consistency and size of the BM. A review of the facility's Bowel Management Protocol indicated that CNAs are required to document the number and size of bowel movements on the resident flow record.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and response to security door alarms, resulting in a resident with severe cognitive impairment eloping from the dementia unit. The resident, who had a history of exit-seeking behavior and was at high risk for elopement, managed to leave the facility through a malfunctioning service gate. The gate's sensor was not functioning due to a past accident, and it was left open, providing the resident access to a busy street outside the facility grounds. On the night of the incident, multiple staff members were aware of the security door alarm sounding but did not respond promptly. The alarm was heard by several staff members, including a CNA and an LVN, who were occupied with other tasks and assumed someone else would respond. The resident was last seen in the hallway before the alarm went off and was found approximately a quarter of a mile away from the facility by the administrator. Interviews with staff revealed that the resident often attempted to leave the facility when he did not get a cigarette, a behavior known to the staff. Despite this knowledge, the facility's policy and procedure for safety and supervision were not adequately followed, as staff did not respond immediately to the alarm, and the malfunctioning service gate was not repaired in a timely manner, leading to the resident's elopement.
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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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