Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Del Sol Care Center during CMS and state inspections, most recent first.
A resident with intact cognition reported to a CNA that another CNA made an inappropriate comment and kissed the resident during care. The CNA who received the report did not notify the Administrator or DON within the required timeframe, instead waiting until the next day to inform a supervisor, contrary to facility policy requiring immediate reporting of abuse allegations.
A CNA was hired and began working without a completed and accurate background check, as required by the facility's abuse prevention policy. The CNA's file contained a record for a registered sex offender that did not match the CNA's identification, and both the DSD and DON confirmed the background check process was not properly followed, creating a risk for resident safety.
A resident with reduced mobility and altered mental status was the subject of sexual abuse allegations that were not investigated or reported to CDPH, the Ombudsman, or law enforcement within the required two-hour window. Facility staff did not follow established protocols, including immediate reporting and suspension of the accused employee, resulting in delayed investigation and notifications.
A resident with dementia and a history of falls was not provided with updated or individualized fall prevention interventions after repeated incidents. Despite staff awareness that existing measures, such as call light reminders, were ineffective due to the resident's cognitive impairment, the care plan was not revised following another unwitnessed fall that led to hospital evaluation. Facility policy required ongoing assessment and revision of care plans, but staff practice was to create new plans for each fall without updating interventions, resulting in continued risk.
A resident with severe cognitive impairment and total dependence on staff for care accused a CNA of sexual abuse, but the CNA was not immediately suspended as required by facility policy. The CNA continued to work the rest of the shift and returned the next day, resulting in the resident not being protected from potential further harm or retaliation.
A resident with severe cognitive impairment and functional quadriplegia reported inappropriate touching and sexually suggestive comments by a staff member. Although internal staff were notified and the accused staff member was suspended, the facility did not report the abuse allegation to the Department of Public Health, Ombudsman, or law enforcement within the required two-hour window, as confirmed by staff interviews and documentation. This delay in reporting constituted a deficiency in following abuse investigation and reporting protocols.
The facility failed to date and properly store respiratory equipment for two residents with COPD, increasing the risk of infection. Observations revealed undated nasal cannulas, nebulizer tubing, and humidifiers, with nebulizer masks left uncovered. The facility's policy requires weekly changes and proper storage to prevent infections.
A resident with multiple health conditions did not receive their prescribed Aspercreme Lidocaine Patch for knee pain due to a failure in the medication refill process. The facility's staff did not follow up on a payment authorization request from the pharmacy, resulting in the medication not being delivered and administered as ordered.
The facility failed to maintain documentation and evidence of its QAPI program, with no updated QAPI binder or meeting records available. The last recorded meeting was in 2021, and key staff could not provide current reports or recall recent meetings. The Medical Director's frequent postponement of meetings further contributed to the deficiency.
The facility failed to conduct regular QAPI meetings and maintain necessary documentation, with the last meeting recorded in 2021. The absence of updated QAPI binders and Infection Control Quarterly Summary Reports was noted, and meetings were often postponed due to the Medical Director's unavailability. This deficiency was identified during interviews and record reviews, highlighting a lack of adherence to the facility's policy for monthly QAPI committee meetings.
The facility's QAPI committee failed to meet quarterly and lacked updated documentation, with the last meeting held in 2021. The absence of current Infection Control Quarterly Summary Reports and frequent postponements by the Medical Director contributed to non-compliance with regulatory requirements.
A resident with multiple diagnoses, including schizophrenia, did not have a care plan addressing their mental health condition. Despite the facility's policy requiring a comprehensive care plan within seven days of the MDS assessment, this was not completed. A registered nurse confirmed the absence of the care plan and was unsure why it was not triggered.
A facility failed to update a resident's care plans as required by their policy. The resident, with multiple diagnoses including COPD and schizoaffective disorder, had care plans that were not revised quarterly or with changes in condition. This oversight was confirmed by an RN during a review, highlighting a risk of inappropriate care due to non-compliance with facility procedures.
A facility failed to ensure a physician reviewed pharmacy recommendations for a resident, risking unnecessary medication doses. The resident, with multiple health issues, was on medications like Risperdal, Xanax, and Nortriptyline. A note recommending against dose reduction lacked a physician's signature date, and the Director of Nursing was unavailable to access these recommendations.
A facility failed to accurately document the administration of a topical pain relief patch for a resident with multiple diagnoses, including dementia. The eMAR showed daily administration of the patch, despite it not being available due to a lack of proper refill request and payment authorization. Nursing staff were unable to account for the documented administrations, leading to a recognized medical error and falsification of records.
A resident with multiple health conditions experienced a fall resulting in a hip fracture. The facility failed to notify the attending physician of the x-ray results in a timely manner, delaying definitive care. The night shift nurse attempted to contact the physician multiple times without success and did not escalate the situation. The resident experienced pain and was given Tylenol, but the lack of communication and escalation led to a delay in treatment.
The facility did not meet federal regulations for room size, with 11 out of 20 rooms failing to provide the required 80 square feet per resident. Despite this, observations showed residents had enough space to move and receive care. The facility's policy aimed to comply with regulations, but room sizes were insufficient.
The facility failed to conduct annual fire safety training for all eight kitchen staff members, as required by policy. The dietary cook reported receiving training only upon hire and during a fire incident, with no other sessions documented. The dietary supervisor confirmed the lack of ongoing training, and the facility administrator acknowledged the necessity of annual competencies. This deficiency could lead to a knowledge and training deficit among the kitchen staff.
A resident experienced severe weight loss and malnutrition due to the facility's failure to provide adequate food and nutritional support. The facility did not monitor the resident's food intake, failed to develop appropriate interventions, and did not follow its policies on fortified diets and weight variance assessment. The resident was frequently agitated and complained of hunger, but the Registered Dietitian was not promptly notified or involved in addressing the weight loss.
A resident with COPD and a history of pneumonia experienced a four-day delay in receiving appropriate respiratory care, leading to symptoms such as inability to sleep, fatigue, poor appetite, and loss of taste. The facility failed to monitor the resident's condition, perform a complete respiratory assessment, and notify the attending physician about the worsening cough and chest X-ray results. The resident was eventually transferred to a hospital and diagnosed with pneumonia.
The facility failed to ensure that eight residents had Advanced Directives Acknowledgement forms documented in their active medical records. These forms were missing from the medical charts, potentially denying residents the right to request or refuse medical care and treatment. The forms were found to be kept in a binder in the Social Service Director's office instead of the residents' medical records.
The facility failed to ensure that four residents were free from physical restraints, specifically the use of bilateral full side rails while in bed, without proper documentation, assessment, or consent. This oversight had the potential to result in entrapment and possible injury to the residents involved.
The facility failed to develop and implement comprehensive care plans for six residents, leading to deficiencies in their care. This included not creating care plans following changes in conditions for two residents, not developing care plans for the use of bed side rails for three residents, and not implementing a comfort measure care plan for one resident.
A resident's medications were left unattended at the bedside during a medication pass, despite the resident having moderate cognitive impairment and requiring maximal assistance for daily activities. The LVN acknowledged that this practice was unsafe, and the facility's policies were not followed.
The facility failed to ensure staff competencies, resulting in two staff members not having up-to-date BLS/CPR certifications and an LVN improperly administering medications by crushing them together, including a medication that should not be crushed. The DON confirmed these deficiencies, which compromised resident safety.
The facility failed to follow standardized recipes and portion sizes for residents on mechanical soft diets, resulting in under-serving Baked Ziti and not adequately moistening garlic toast, which could lead to meal dissatisfaction and potential health risks.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper storage of vanilla pudding next to raw eggs, a plastic cup in contact with dried chicken base powder, and expired nutritional supplements. Additionally, the ice machine was not maintained in a sanitary manner, and food brought in by residents was not properly labeled or dated.
The facility failed to maintain accurate medical records by not ensuring that advance directive acknowledgment forms were easily accessible in the medical charts of eight residents. The forms were completed but kept in the Social Service Director's office instead of the residents' charts, contrary to the facility's policy.
A facility failed to promote a resident's dignity by allowing a CNA to stand over a resident while feeding them. The resident, who had severe malnutrition, diabetes, and impaired cognition, had to extend his neck to look up at the CNA. The CNA admitted this practice might seem like rushing the resident and is less comfortable for them.
The facility failed to accommodate the needs and preferences of two residents. One resident's scheduled activities were frequently canceled due to staff shortages, while another resident's bed was too short for their height, leading to poor body positioning. These deficiencies were confirmed by staff and were contrary to the facility's policies.
The facility failed to protect a resident's medical record when a medication cart laptop screen displaying the resident's information was left open and unattended in the hallway. The resident had multiple diagnoses and required moderate supervision for daily activities. Facility policies on confidentiality and resident rights were not followed, leading to a potential violation of the resident's privacy.
The facility failed to report and investigate an unusual occurrence and injury of unknown source for a resident with a history of diabetes, cerebral infarction, and dementia. The resident was found on the floor with abrasions, but the incident was not reported to the appropriate authorities or investigated further, delaying an onsite inspection and potentially placing residents at further risk.
The facility failed to report an unusual occurrence and injury of unknown source within 24 hours for a resident with a history of diabetes, cerebral infarction, and dementia. The resident was found on the floor with abrasions, and the incident was not reported to the appropriate authorities, resulting in a delay of an onsite inspection by the State Agency.
The facility failed to ensure proper use of low air loss mattresses for two residents at risk for pressure injuries. One resident's mattress was found turned off, causing discomfort and potential exacerbation of a stage four pressure ulcer. Another resident's mattress was incorrectly set for a lower weight than the resident's actual weight, risking delayed wound healing and further pressure ulcers.
The facility failed to ensure a resident received appropriate treatment and services to maintain or improve ROM and mobility. The resident, with hemiplegia and hemiparesis, was observed multiple times lying laterally sideways on the bed with both feet hanging off. Staff did not consistently follow the care plan to reposition the resident every two hours, and refusals were not documented as required by facility policy.
The facility failed to post the actual hours worked by nursing staff for three consecutive days, posting only projected hours instead. The IPN/DSD confirmed the practice and was initially unsure of the requirement to post actual hours, which was later confirmed by the facility's policy.
The facility failed to manage medications from the emergency kit properly and did not adhere to professional standards for medication administration. An LVN was observed crushing multiple medications together, including Proscar, which should not be crushed. This affected a resident with multiple medical conditions, and the facility's policies for safe medication administration were not followed.
The facility failed to implement Gradual Dose Reductions (GDR) for two residents, leading to potential overuse of antipsychotic medications. Despite recommendations from the Pharmacist Consultant, there was no follow-up with the physician to evaluate the necessity of the dose reductions, putting the residents at risk for unnecessary medications.
A facility failed to ensure medications were not crushed together, resulting in a 16% medication error rate. An LVN was observed crushing five medications, including Proscar, which should not be crushed due to its teratogenic properties. The DON confirmed the improper practice and the lack of a reference list on the medication cart.
A facility failed to dispose of a resident's Levalbuterol HCL nebulizer medication within the two-week period recommended by the manufacturer. The resident, who had severe cognitive impairment and required assistance for daily activities, was at risk for respiratory difficulties due to this oversight.
The facility failed to update the Facility Assessment (FA) to include the Activity Director (AD) and Social Service Director (SSD) in the staffing plan. The Director of Nursing (DON) acknowledged the omission and emphasized the importance of including both AD and SSD in the FA to ensure comprehensive resident care.
The facility failed to implement its antibiotic use protocol and did not monitor actual antibiotic use for two residents. The absence of an antibiotic surveillance log, as confirmed by the IPN and DON, led to the potential for unnecessary and inappropriate antibiotic use, risking antibiotic resistance.
The facility failed to ensure that 10 out of 20 resident rooms met the square footage requirement of 80 square feet per resident. Rooms 104, 105, 106, 107, 108, 109, 116, 117, 119, and 120 were found to have less than the required space per resident, with each room accommodating three residents but providing only between 66.30 and 74.73 square feet per resident. Despite this, residents and staff reported having enough space to move freely and for nursing staff to provide care.
Failure to Timely Report Alleged Abuse by CNA
Penalty
Summary
Certified Nurse's Aide (CNA) 3 failed to report an allegation of abuse made by a resident to the facility Administrator within the required 2-hour timeframe, as mandated by facility policy. The resident, who had intact cognition and the capacity to make medical decisions, reported that another CNA made an inappropriate comment about the resident's body and kissed the resident on the cheek while providing care. The resident immediately informed CNA 3 of the incident. However, CNA 3 did not report the allegation to the Administrator or Director of Nursing Service as required, instead finishing charting and leaving the facility without notifying anyone. CNA 3 acknowledged during an interview that the allegation should have been reported right away but was only communicated to a supervisor the following day when CNA 3 returned to work. Facility policy, which CNA 3 had received training on, clearly states that all employees must immediately report any suspected or actual abuse to the Administrator and/or Director of Nursing Service. The failure to promptly report the allegation delayed the facility's response and investigation into the reported abuse.
Failure to Complete Pre-Employment Background Check for CNA
Penalty
Summary
The facility failed to implement its abuse prevention program policy and procedure by not verifying a potential candidate's background check for a history of abuse, neglect, or mistreatment prior to employment. Specifically, a Certified Nursing Assistant (CNA) was hired and began working without a completed and accurate background check. The CNA's file contained a record indicating a registered sex offender, but the name and date of birth on this record did not match the CNA's identification. The Director of Staff Development (DSD) acknowledged that the pre-employment verification process should have ensured the accuracy of the CNA's name and date of birth before the employee's start date, but was unsure how the incorrect document was included in the file. During interviews, the DSD and the Director of Nurses (DON) both confirmed that the required background check was not properly completed, and the DON stated that failing to conduct an employee background check puts residents at risk of abuse and is a safety concern. Review of the facility's Abuse Prevention Program policy indicated that thorough employee background checks are required and that individuals convicted of abuse, neglect, or mistreatment should not be employed. The facility's failure to follow this policy had the potential for mistreatment, neglect, misappropriation of property, and abuse of residents.
Failure to Timely Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to investigate and report allegations of sexual abuse involving a resident in a timely manner, as required by policy and regulation. After a resident with reduced mobility, altered mental status, and hypertension was transferred to a hospital, the facility's social services director was contacted by a hospital social worker regarding abuse allegations. Despite being informed of the allegations, the facility had not initiated an investigation or reported the incident to the California Department of Public Health (CDPH), the Ombudsman, or local law enforcement within the required two-hour timeframe. The staff member accused of abuse was also not suspended immediately following the allegation. Interviews with facility staff, including the CNA, social services director, MDS coordinator, Director of Staffing Development, Director of Nursing, and Administrator, confirmed that the established protocol for abuse allegations—which includes immediate reporting, investigation, and suspension of the accused staff—was not followed. The facility's own policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, and that employees accused of abuse are to be suspended pending investigation. These steps were not taken, resulting in a delay in both the investigation and required notifications.
Failure to Revise Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to revise fall prevention interventions for a resident with a history of dementia, lack of coordination, and difficulty walking, who was identified as being at high risk for falls. Despite multiple documented falls and a high fall risk score, the resident's care plan and fall risk assessments were not updated with new or revised interventions after a subsequent unwitnessed fall. The care plan continued to include interventions such as keeping the call light within reach and reminding the resident not to get up without assistance, which staff acknowledged were ineffective due to the resident's cognitive impairment. On the date of the incident, the resident experienced an unwitnessed fall and was found on the floor, prompting a transfer to an acute care hospital for evaluation. Medical imaging at the hospital revealed no acute injuries, but the resident was classified as high risk for further falls due to age and dementia. Interviews with facility staff, including a CNA, LVN, RN Supervisor, and DON, confirmed that the care plan was not appropriately revised to address the repeated falls, and that interventions remained unchanged despite evidence they were not effective for this resident's condition. Facility policies required ongoing assessment and revision of care plans as residents' conditions changed, and specifically called for re-evaluation and modification of interventions if falls continued. However, the staff practice was to create new care plans for each fall incident without revising existing interventions, resulting in a lack of effective, individualized fall prevention strategies for the resident. This failure to update and individualize the care plan contributed to the resident's repeated falls and the associated risks.
Failure to Immediately Remove Staff Accused of Sexual Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policy when a resident accused a Certified Nursing Assistant (CNA) of sexual abuse. The resident, who had functional quadriplegia, schizophrenia, severe cognitive impairment, and was fully dependent on staff for toileting, reported that the CNA touched her inappropriately and made sexually suggestive comments. The allegation was documented by staff, and the resident's physician and psychiatrist were notified. Despite the policy requiring immediate suspension of any employee accused of abuse, the CNA continued to work the remainder of the shift on the day of the allegation and returned to work the following day. Documentation and interviews confirmed that the CNA was not suspended until the day after the allegation was made, allowing continued access to the resident and other residents during this period. Staff interviews indicated that the standard procedure was to suspend accused employees immediately to protect residents from further harm or retaliation, but this was not followed in this instance. The facility's own policies, reviewed in August 2024, clearly stated that employees accused of abuse must be suspended immediately to prevent further potential abuse, neglect, exploitation, or mistreatment. However, the failure to remove the CNA from resident care after the allegation resulted in the resident not being protected from the potential of further harm or retaliation by the accused staff member.
Failure to Timely Report and Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate and report an allegation of sexual abuse involving a resident in accordance with its own policy and regulatory requirements. The resident, who had functional quadriplegia, schizophrenia, severe cognitive impairment, and was dependent on staff for toileting, reported that a staff member had touched her inappropriately and made sexually suggestive comments. The allegation was communicated to various staff members, including a Certified Occupational Therapy Assistant, the Director of Rehabilitation, the Social Services Director, and the Director of Nursing. The resident's care plan was updated to address emotional distress, and the accused staff member was suspended from working with the resident. Despite these internal actions, the facility did not report the allegation to the Department of Public Health, the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's Abuse Investigation and Reporting policy. Documentation and interviews confirmed that notifications to mandated entities were made after 7 PM on the day of the allegation and to law enforcement the following day, well beyond the two-hour window. Multiple staff interviews corroborated that the policy required immediate reporting, and the delay was acknowledged by the Director of Nursing and other staff. The failure to report the abuse allegation in a timely manner constituted a deficiency, as it delayed the involvement of external authorities and the initiation of an independent investigation. The report specifically notes that this delay had the potential to place the resident at further risk and to delay an onsite inspection by regulatory and law enforcement agencies.
Failure to Date and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, identified as Residents 23 and 21, by not dating the nasal cannula, nebulizer tubing, and humidifier, and by not covering the nebulizer mask after use. Resident 23, who was readmitted with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen, had a care plan indicating a risk for ineffective airway clearance and respiratory infections. During an observation, it was noted that Resident 23's nasal cannula, nebulizer tubing, and humidifier were not dated, and the nebulizer mask was left uncovered on top of the nebulizer machine. Resident 23 could not recall when these items were last changed, and the Registered Nurse Supervisor/Infection Prevention Nurse confirmed that these items should be dated and changed weekly to prevent infection. Similarly, Resident 21, who was readmitted with COPD and chronic respiratory failure, also had undated nasal cannula, nebulizer tubing, and humidifier, with the nebulizer mask left uncovered. Resident 21's care plan also indicated a risk for ineffective airway clearance and respiratory infections. During an observation, Resident 21 was unable to remember the last time the respiratory equipment was changed. The Registered Nurse Supervisor/Infection Prevention Nurse reiterated that the equipment should be changed weekly and dated to prevent infections. The facility's policy on respiratory care routine equipment change, revised in December 2024, requires that oxygen cannula tubing be changed every seven days and stored in a plastic bag when not in use. The failure to adhere to these procedures could have resulted in Residents 23 and 21 acquiring respiratory infections, as the equipment was not dated or stored properly, increasing the risk of contamination.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility's licensed nursing staff failed to administer pain medication as prescribed to one resident, identified as Resident 20. The resident was admitted with multiple diagnoses, including joint disorders, contracture of the right knee, muscle weakness, Alzheimer's, dementia, and a history of myocardial infarction. The resident's cognitive skills were moderately impaired, and they lacked the capacity to make decisions due to dementia. The prescribed medication, an Aspercreme Lidocaine Patch 4% for right knee pain, was not administered as ordered because it was not available in the medication cart. The Licensed Vocational Nurse (LVN) stated that a refill request was made to the contracted pharmacy two days prior, but the medication had not been delivered. Further investigation revealed that the pharmacy had not received a recent refill request for the medication. The last request was made over a month prior, and the pharmacy had sent a payment authorization request to the facility, which was not responded to, resulting in the medication not being delivered. The facility's policy requires medications to be administered within one hour of the prescribed time, and any issues with medication availability should be followed up promptly. However, there was no record of a follow-up with the pharmacy regarding the missing medication, leading to the resident not receiving their prescribed pain relief patch.
Lack of QAPI Documentation and Meetings
Penalty
Summary
The facility failed to maintain documentation and evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. During an interview and concurrent record review, it was revealed that the facility did not have a comprehensive QAPI program and plan in place. The Administrator stated that the Director of Health Information was responsible for maintaining the QAPI and Quality Assessment and Assurance (QAA) documents, but no binder or documents were available during the meeting. The last recorded QAPI and QAA meeting was on 9/19/2021, and there was no updated QAPI binder or list of reviewed and updated policies from the last meeting. The Administrator acknowledged the importance of QAPI and QAA meetings to ensure residents receive the best care, yet the necessary documentation was not available for review. Further interviews revealed that the Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse did not have any current Infection Control Quarterly Summary Reports. The Director of Health Information confirmed the absence of an updated QAPI binder for 2024 or 2025 and could not recall the last QAPI and QAA committee meeting. Additionally, the Director of Social Service mentioned that the Medical Director frequently postponed meetings due to other commitments. The facility's policy and procedures indicated that the QAPI committee should meet monthly to review reports and monitor quality-related activities, but this was not being adhered to, leading to the deficiency.
Failure to Conduct Regular QAPI Meetings and Maintain Documentation
Penalty
Summary
The facility failed to maintain effective systems for obtaining and utilizing feedback from direct care staff, other staff, residents, and resident representatives. This deficiency was identified during an interview and record review, where it was revealed that the facility did not conduct monthly and quarterly Quality Assurance and Performance Improvement (QAPI) meetings as required. The last recorded QAPI meeting was on September 19, 2021, and there was no updated QAPI binder or documentation available for review. The Administrator acknowledged the absence of a list of reviewed and updated policies from the last QAPI meeting and admitted to not having the last monthly QAPI minutes and committee signatures on hand. Further interviews revealed that the Director of Health Information did not have an updated QAPI binder for 2024 or 2025, and the last available binder was from 2023. The Director of Social Service mentioned that the QAPI and QAA meetings were often postponed due to the Medical Director's unavailability. Additionally, the RNS/ADON/IPN stated that the lack of current Infection Control Quarterly Summary Reports could delay tracking infections and outcomes. The facility's policy indicated that the QAPI committee should meet monthly to review reports and monitor quality-related activities, but this was not being adhered to, leading to the deficiency.
QAPI Committee Fails to Meet Regulatory Requirements
Penalty
Summary
The facility failed to meet the regulatory requirements for the Quality Assurance and Performance Improvement (QAPI) committee, as it did not meet quarterly and did not receive reports from the Infection Preventionist on the Infection Prevention and Control Program. During an interview and record review, it was revealed that the last QAPI and Quality Assessment and Assurance (QAA) meeting was held on September 19, 2021, and there were no updated QAPI binders or documents available for review. The Administrator acknowledged the absence of a current QAPI binder and the lack of a list of reviewed and updated policies from the last QAPI meeting. Additionally, the Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse (RNS/ADON/IPN) confirmed the absence of current Infection Control Quarterly Summary Reports. The Director of Health Information also stated that there were no updated QAPI binders for 2024 or 2025, and she could not recall the last QAPI and QAA committee meeting. The Director of Social Service mentioned that the Medical Director frequently postponed meetings due to scheduling conflicts. The facility's policy on QAPI, dated February 26, 2024, mandates monthly meetings to review reports and evaluate data, but this was not adhered to. This lack of compliance resulted in the QAPI committee not being able to establish performance and outcomes for the quality of care and services delivered in the facility.
Lack of Care Plan for Schizophrenia in Resident
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident diagnosed with schizophrenia. The resident, who was admitted to the facility with multiple diagnoses including schizophrenia, did not have a care plan addressing this mental health condition. This oversight was identified during a record review and interview with a registered nurse, who acknowledged the absence of a care plan for schizophrenia and was unsure why it had not been triggered. The resident's admission records and Minimum Data Set (MDS) indicated a diagnosis of schizophrenia, along with other conditions such as COPD, morbid obesity, anemia, gout, general anxiety disorder, asthma, major depressive disorder, and insomnia. The resident required maximal assistance with daily activities due to moderately impaired cognition. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the MDS assessment, but this requirement was not met for the resident's schizophrenia diagnosis.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that a resident's care plans were revised according to their policy and procedures. The resident, who was admitted with multiple diagnoses including COPD, morbid obesity, anemia, gout, general anxiety disorder, asthma, major depressive disorder, schizoaffective disorder bipolar type, and insomnia, had care plans that were not updated as required. The resident's minimum data set indicated moderately impaired cognition and a need for maximal assistance with daily activities. Despite these needs, the care plans related to the resident's use of hypnotic medication for insomnia and psychotropic medication for bipolar disorder had not been updated since their creation. During an interview and record review, a registered nurse confirmed that the care plans had not been updated quarterly or with changes in the resident's condition, as stipulated by the facility's policy. The policy required the interdisciplinary team to monitor and document any changes in behavior, mood, and function, and to adjust interventions accordingly. The failure to update the care plans placed the resident at risk of receiving inappropriate care, as the facility did not adhere to its own procedures for monitoring and adjusting care based on the resident's condition.
Failure to Review Pharmacy Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that the physician reviewed the monthly medication review recommendation from the pharmacy for one of the sampled residents, identified as Resident 14. This oversight placed Resident 14 at risk of receiving an unnecessary dose of antipsychotic medications. Resident 14 was admitted with multiple diagnoses, including low back pain, COPD, diabetes mellitus, major depressive disorder, and anxiety. The resident's minimum data set indicated that their cognition was not intact, and they required maximum assistance with daily activities. The physician orders included medications such as Risperdal, Xanax, and Nortriptyline for various conditions. During a review, it was found that a note to the attending physician prescriber dated January 16, 2025, recommended against a gradual dose reduction for these medications due to ongoing symptoms. However, the note lacked a date next to the physician's signature, indicating a failure to document the review and any actions taken. The Registered Nurse (RN) stated that the recommendations are usually sent to the Director of Nursing, who was unavailable, leading to a lack of access to these recommendations. The facility's medication regimen review policy requires timely physician response and documentation of any irregularities, which was not adhered to in this case.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one resident by inaccurately documenting the administration of a topical pain relief patch. The resident, who was admitted with multiple diagnoses including joint disorders, muscle weakness, Alzheimer's, and dementia, had an order for an Aspercreme Lidocaine Patch 4% to be applied daily for right knee pain. However, during a medication administration observation, it was found that the patch was not available in the medication cart, and a refill request had not been properly processed or confirmed with the pharmacy. Further investigation revealed that the pharmacy had not received a recent refill request due to a lack of response from the facility regarding a payment authorization issue. Despite this, the electronic medication administration records (eMAR) indicated that the patch had been administered daily over several months. Interviews with nursing staff revealed inconsistencies and an inability to account for the administration of the patches, which had not been delivered since the previous October. This discrepancy in documentation was acknowledged as a medical error and falsification of records by the facility's registered nurse.
Delayed Notification of Hip Fracture X-Ray Results
Penalty
Summary
The facility failed to notify the attending physician of x-ray results indicating a hip fracture for a resident in a timely manner. The resident, who had a history of atrial fibrillation, lack of coordination, anemia, hypothyroidism, hyperlipidemia, Alzheimer's, hypertension, and gastroesophageal reflux disease, was admitted to the facility and had an unsteady gait without using assistive devices. After a fall, the resident was found with a hematoma on the head and was ordered a stat x-ray for the right hip. The x-ray results, which showed an acute impacted subcapital femoral neck fracture, were available at 7:46 p.m. but were not communicated to the physician until the following morning. The night shift nurse attempted to contact the attending physician multiple times without success and did not escalate the situation to the medical director or use clinical judgment to transfer the resident to a hospital. The resident experienced pain and was given Tylenol, but definitive care was delayed. The facility's policy required notifying the attending physician or physician on call in case of significant changes in a resident's condition, but this was not followed. The attending physician did not respond, and the contact information for the on-call physician was not shared with the night staff, leading to further delays. Eventually, the on-call physician was contacted, and the resident was transferred to a hospital for treatment.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 11 out of 20 resident rooms did not meet the 80 square feet per resident requirement. These rooms were observed to have three beds each, with measurements ranging from 66.3 to 78.39 square feet per resident, which is below the federal standard. The facility had previously submitted a Request for Renewal of Room Size Waiver, acknowledging that 10 rooms did not meet the requirement, but upon further observation, it was found that 11 rooms were non-compliant. Despite the deficiency in room size, general observations indicated that residents had ample space to move freely within their rooms, and there was sufficient space for nursing staff to provide care. The rooms were equipped with necessary furniture and equipment, allowing for freedom of movement. The facility's policy, updated in August 2024, stated the intent to provide areas large enough to accommodate residents' needs in accordance with state and federal regulations, yet the observed room sizes did not align with these standards.
Failure to Conduct Annual Fire Safety Training for Kitchen Staff
Penalty
Summary
The facility failed to ensure that the kitchen staff met the annual in-service training sessions and evaluation requirements on fire prevention for all eight kitchen staff members. During an interview, the dietary cook (DC) mentioned that he received fire and safety training only upon hire and on the day of a fire incident, with no recollection of any other training sessions. A review of the DC's employee record and the dietary in-service binder confirmed the lack of documented evidence of additional fire safety training. The dietary supervisor (DS) admitted that no fire and safety training had been conducted for the kitchen staff since their initial hiring. The facility administrator (FA) acknowledged that competencies for fire and safety should be conducted annually to ensure staff capability and knowledge. The facility's policy, dated 1/1/2017, requires all dietary employees to attend annual in-service sessions on fire prevention, which was not adhered to, leading to a potential knowledge and training deficit among the kitchen staff.
Failure to Provide Adequate Nutrition and Address Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident at risk for dehydration and malnutrition was offered sufficient food and did not experience unplanned severe weight loss. The facility did not identify interventions related to the resident's poor food intake since admission, failed to monitor and document the resident's high protein nutrition intake, and did not develop interventions including frequent foods and snacks when the resident yelled or asked for food. Additionally, the Registered Dietitian did not promptly evaluate the resident after a significant weight loss was identified, and the facility did not implement its policy on fortified food programs to provide appropriate substitutes for the resident who had intolerance to dairy products. The resident experienced a severe weight loss of 12 pounds in one month, which was equivalent to 7.8% of their body weight. The resident was observed to be agitated, complained of being hungry, and frequently requested more food. Despite these signs, the resident was not assessed and re-evaluated by a Registered Dietitian for 20 days after the significant weight loss was identified. The facility also failed to implement its policy on weight variance assessment and interventions when the resident's weight loss was identified. The resident's care plan interventions related to alteration in nutrition, severe protein-calorie malnutrition, and weight loss were not implemented. The resident's meal consumption percentages were inconsistently recorded, and the high protein nutrition intake was not documented. The facility's failure to address these issues resulted in the resident experiencing severe protein-calorie malnutrition and agitation due to hunger. The facility's policies on fortified diets and weight variance assessment were not followed, leading to inadequate nutritional support for the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with COPD and a history of pneumonia. The resident developed a cough, but the facility did not closely monitor the resident's respiratory condition or perform a complete respiratory assessment as per their policies and procedures. Additionally, the facility did not notify the attending physician about the resident's worsening cough or the chest X-ray results that recommended further action if symptoms persisted or worsened. The resident experienced a four-day delay in receiving appropriate respiratory care, leading to symptoms such as inability to sleep, fatigue, poor appetite, and loss of taste. The resident's condition deteriorated, resulting in a transfer to a general acute care hospital where they were diagnosed with pneumonia and required intravenous antibiotics. The facility's failure to promptly assess and address the resident's respiratory issues, as well as the lack of communication with the attending physician, contributed to the resident's worsening condition and subsequent hospitalization. The Director of Nursing admitted that the respiratory assessment should have been performed earlier and that the physician should have been notified about the chest X-ray results and the resident's symptoms.
Failure to Document Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that eight of 16 sampled residents had Advanced Directives Acknowledgement forms documented in their active medical records. This deficiency was identified during interviews and record reviews, revealing that the forms were missing from the medical charts of Residents 1, 9, 21, 23, 24, 25, 189, and 190. These residents had various medical conditions, including diabetes mellitus, urinary tract infections, epilepsy, severe protein-calorie malnutrition, recurrent depressive disorder, encephalopathy, chronic obstructive pulmonary disease, dysphagia, cerebral infarction, hemiplegia, hemiparesis, and sepsis. The residents exhibited varying levels of cognitive impairment and required different levels of assistance for activities of daily living (ADLs). The absence of these forms in the medical records had the potential to deny these residents the right to request or refuse medical care and treatment. During a concurrent interview and record review with Registered Nurse 1, it was confirmed that the Advanced Directives Acknowledgement Forms were missing from the residents' medical charts. RN 1 stated that these forms were supposed to be completed by the facility staff upon admission and kept in the residents' charts. Further investigation with the Social Service Director revealed that the forms were completed but were kept in a binder inside the SSD's office instead of being placed in the residents' medical records. The SSD acknowledged the oversight and admitted to failing to ensure that the forms were easily accessible. The Director of Nursing also confirmed that the Advanced Directives Acknowledgement Forms should be kept in the residents' medical records for easy access when needed. A review of the facility's policy and procedure on Advance Directives indicated that information about whether or not the resident has executed an advance directive should be prominently displayed in the medical record. The failure to adhere to this policy resulted in the deficiency identified during the survey.
Failure to Ensure Residents Were Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that four residents were free from physical restraints, specifically the use of bilateral full side rails while in bed. Resident 25 was found with bilateral full side rails up without documentation of less restrictive measures being attempted first. The facility's policy requires that less restrictive measures be exhausted before resorting to full side rails, and this was not followed. Additionally, there was no comprehensive care plan or physician's order for the use of these side rails for Resident 25. For Residents 9, 21, and 189, the facility failed to obtain the necessary physician's orders and informed consents for the use of bilateral side rails. Resident 9 was observed with bilateral upper side rails up, but there was no physician's order or informed consent documented. Similarly, Resident 21 and Resident 189 were found with bilateral full side rails up without the required physician's orders and informed consents. The facility's policy mandates an interdisciplinary assessment, consultation with the attending physician, and input from the resident or their legal representative before using side rails, which was not adhered to in these cases. The facility's policies on side rails and bed safety were not followed, leading to the use of physical restraints without proper documentation, assessment, or consent. This oversight had the potential to result in entrapment and possible injury to the residents involved. The staff confirmed the lack of physician's orders and informed consents during interviews, acknowledging that these should have been in place to comply with the facility's policies and ensure resident safety.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to deficiencies in their care. For Residents 31 and 13, the facility did not create care plans following changes in their conditions. Resident 31 experienced a cough and congestion, which was later diagnosed as pneumonia, but no care plan was initiated to address these symptoms. Similarly, Resident 13 developed a persistent cough after receiving a COVID vaccination, but no care plan was created to manage this condition, despite the resident's complaints and visible distress during an interview and observation by staff. The facility also failed to develop care plans for the use of bed side rails for Residents 9, 21, and 189. These residents had assessments indicating the need for side rails for mobility aid and safety, but there were no corresponding care plans or physician orders documented. Observations confirmed that these residents were using side rails without the necessary care plans or informed consent, which is against the facility's policy and procedures. Additionally, the facility did not implement a comfort measure care plan for Resident 37, who had orders for comfort measures every shift. Despite the order being in place, the care plan was missing, and the registered nurse confirmed that it should have been initiated to provide proper care. This lack of comprehensive care planning had the potential to negatively impact the health, safety, and quality of care for the affected residents.
Unattended Medications at Bedside
Penalty
Summary
The facility failed to provide an environment free from accident hazards by leaving Resident 3's medications unattended at the bedside during a medication pass. Resident 3, who has moderate cognitive impairment and requires maximal assistance for activities of daily living, was observed with their morning medications left unattended on the bedside table. This observation was made while the Licensed Vocational Nurse (LVN) was assisting Resident 3's roommate with the curtain closed. The LVN acknowledged that medications should not be left unattended for safety reasons. Resident 3's medical history includes diabetes mellitus, atrial fibrillation, and schizophrenia. The facility's policy and procedures for administering medications and ensuring resident safety and supervision were reviewed, indicating that medications should be administered safely and timely, and the environment should be as free from accident hazards as possible. However, the facility did not adhere to these policies, resulting in the potential for unsafe medication administration to Resident 3.
Failure to Ensure Staff Competencies and Safe Medication Administration
Penalty
Summary
The facility failed to ensure that staff had the appropriate competencies to provide nursing and related services, which compromised the safety of the residents. Specifically, two staff members, an LVN and a CNA, did not have up-to-date BLS/CPR certifications. The Infection Preventionist Nurse/Director of Staff Development acknowledged that it was their responsibility to ensure that all staff maintained current certifications. The facility's policy required all personnel to be trained and certified in BLS/CPR, but this was not adhered to in these cases, as confirmed by a review of staff files and interviews. Additionally, the facility did not ensure that an LVN had the necessary competencies to perform safe medication administration for a resident. During a medication administration observation, the LVN was seen crushing multiple medications together, including Proscar, which should not be crushed according to the manufacturer's guidelines. The DON confirmed that crushing medications together is considered compounding and that Proscar must not be crushed. The facility's policy required medications to be administered safely and as prescribed, but this was not followed in this instance. The resident involved had multiple diagnoses, including Benign Prostatic Hyperplasia, secondary hypertension, and hyperlipidemia, and was dependent on staff for activities of daily living. The improper medication administration practice was observed and confirmed by the DON, who admitted that each medication cart should have had a list of medications that should not be crushed. The facility's job descriptions and policies emphasized maintaining an acceptable standard of nursing practice and ensuring staff competencies, but these were not upheld in the observed instances.
Failure to Follow Standardized Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure the standardized recipes for the lunch menu were followed on 3/23/24. Specifically, the cook used a smaller scoop size to serve Baked Ziti to five residents on a mechanical soft finely chopped diet, resulting in them receiving 1/2 cup instead of the required 1 cup. This discrepancy was confirmed through interviews with the cooks and the Dietary Supervisor, who acknowledged that the residents received less food than prescribed, which could potentially lead to weight loss. Additionally, 17 residents on a mechanical soft diet did not receive garlic toast in a texture that met their needs, as the toast was not adequately moistened with the required 1-2 teaspoons of margarine, increasing the risk of choking. The Dietary Supervisor confirmed that the recipe required additional margarine for residents on a mechanical soft diet to ensure the bread was adequately moistened. During the observation of the tray line service for lunch, it was noted that the cooks did not follow the menu and portion guide, leading to the deficiencies. The facility's lunch menu and recipes clearly indicated the required portions and preparation methods, but these were not adhered to. Interviews with the cooks and the Dietary Supervisor revealed that the mistakes were acknowledged, and the importance of following the menu and portion guide was emphasized. The failure to follow the standardized recipes and portion sizes resulted in meal dissatisfaction and potential health risks for the residents on mechanical soft diets.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Observations revealed that a large bowl of vanilla pudding was stored on the same shelf next to raw shelled eggs and cartons of raw liquid eggs, which could lead to cross-contamination. Additionally, a small plastic cup was found inside a container of dried chicken base powder, in direct contact with the powder, which is against the facility's policy and could result in contamination. Furthermore, three large containers of vanilla-flavored nutritional supplements were stored in the refrigerator beyond their safe use period, as indicated by the manufacturer's instructions, posing a risk of expired products being consumed by residents. The ice machine in the facility was not maintained in a sanitary manner, with gray and orange residue observed inside the compartment where ice is stored and dispensed. This residue was confirmed by both the Dietary Aide and the Maintenance Supervisor, who acknowledged that the ice machine had not been cleaned in over a month, contrary to the facility's policy of monthly cleaning. The unsanitary condition of the ice machine could lead to contamination of the ice consumed by residents. Food brought in by residents from outside the facility, including leftovers stored in the resident food refrigerator, was not labeled or dated. Observations showed expired yogurt, leftover food, and other items without proper labeling or dates, indicating a failure to follow the facility's policy for handling and storing food brought in by residents. This oversight was confirmed by the Activity Director and the Director of Nursing, who acknowledged that the food was stored beyond the recommended period and some items were not labeled, increasing the risk of foodborne illness among residents.
Failure to Maintain Accessible Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for eight residents by not ensuring that advance directive acknowledgment forms (ADAF) were easily accessible in the residents' medical charts. This deficiency was identified during a review of the medical records and interviews with staff members. The residents affected had various medical conditions, including diabetes mellitus, urinary tract infections, epilepsy, severe protein-calorie malnutrition, recurrent depressive disorder, encephalopathy, chronic obstructive pulmonary disease, dysphagia, cerebral infarction, hemiplegia, hemiparesis, and sepsis. Their cognitive impairments ranged from moderate to severe, and they required varying levels of assistance from staff for activities of daily living (ADLs). The absence of ADAFs in their medical charts had the potential to negatively impact the delivery of care to these residents. During a concurrent interview and record review with a registered nurse (RN), it was confirmed that the ADAFs for the eight residents were missing from their medical charts. The RN stated that these forms were supposed to be completed upon admission and kept in the residents' charts. Further investigation with the Social Service Director (SSD) revealed that the ADAFs were completed but were kept in the SSD's binder inside her office instead of being placed in the residents' medical charts. The SSD acknowledged the oversight and admitted that she failed to ensure the forms were easily accessible. The Director of Nursing (DON) also confirmed that the ADAFs should be kept in the residents' medical records for easy access when needed. A review of the facility's policy and procedures on advance directives indicated that information about whether or not a resident has executed an advance directive should be prominently displayed in the medical record. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Promote Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that promoted or enhanced a resident's dignity and respect by allowing a staff member to stand over a resident while feeding them. During a meal observation, a Certified Nursing Assistant (CNA) was seen standing over a resident who had to extend his neck to look up at the CNA. The CNA admitted to standing while feeding the resident and acknowledged that it might seem like rushing the resident and that it is more comfortable for residents if the staff sits down while feeding them. The resident involved had severe protein-calorie malnutrition, type 2 diabetes mellitus, and recurrent depressive disorder, and required moderate assistance with eating due to severely impaired cognition. The facility's policy and procedures on assistance with meals, revised in July 2017, indicated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, which includes not standing over residents while assisting them with meals.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs and preferences of two residents, Resident 30 and Resident 190. Resident 30, who has diagnoses including toxic encephalopathy, fibromyalgia, and generalized anxiety disorder, expressed that scheduled activities in the Activity Room were not being conducted as frequently due to short staffing. The Activity Director confirmed that they were often reassigned to work as a Certified Nursing Assistant (CNA) when CNAs called off, leading to the cancellation of scheduled activities. The Director of Nursing also acknowledged that the lack of staff resulted in the rescheduling of activities, preventing residents from participating in their preferred activities like Bingo, as indicated in Resident 30's Minimum Data Set (MDS). The facility's policy stated that the Activity Director's primary function is to develop and conduct an activity program to meet the residents' physical, mental, and psychosocial needs, which was not being fulfilled due to staffing issues. Resident 190, who has diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times with both feet hanging off the bottom of the bed. Resident 190's MDS indicated that they had an intact cognition and required moderate assistance for activities of daily living. Despite being 78 inches tall, Resident 190's bed and mattress were not appropriate for their height, leading to poor body positioning and potential risk of contractions. The Registered Nurse and Maintenance Supervisor confirmed that the bed was too short and that extensions could be added to accommodate taller residents. The facility's policy on bed safety and maintenance emphasized regular inspections and adjustments to ensure the safety and comfort of residents, which was not adhered to in this case. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding activity programs and bed safety, potentially impacting the psychosocial well-being and physical health of the residents. The lack of appropriate staffing and equipment adjustments directly contributed to the unmet needs and preferences of Resident 30 and Resident 190, respectively.
Failure to Protect Resident's Medical Record
Penalty
Summary
The facility failed to ensure the protection of a resident's medical record, specifically for Resident 21. During an observation, a medication cart laptop screen displaying Resident 21's information was left open and unattended in the hallway. This incident occurred while Licensed Vocational Nurse 1 (LVN 1) stepped away to talk to a colleague and forgot to close the laptop. LVN 1 acknowledged that the laptop should have been closed to prevent unauthorized viewing of the resident's information, which violates the resident's privacy. Resident 21 had been admitted with diagnoses including toxic encephalopathy, chronic obstructive pulmonary disease (COPD), and muscle wasting and atrophy. The Minimum Data Set (MDS) indicated that Resident 21 had moderately impaired cognitive skills and required moderate supervision for activities of daily living. The facility's policies on confidentiality and resident rights, which were reviewed recently, mandate the protection of resident information and limit access to authorized personnel only. However, these policies were not followed in this instance, leading to a potential violation of Resident 21's right to privacy and confidentiality.
Failure to Report and Investigate Unusual Occurrence
Penalty
Summary
The facility failed to implement its policy regarding the reporting of an unusual occurrence and injury of unknown source for Resident 26. Resident 26, who has a history of unspecified type 2 diabetes mellitus, cerebral infarction, and dementia, was found on the floor with abrasions on the right eye and knee after an unwitnessed fall. Despite the resident's moderate cognitive impairment and inability to recall the incident, the facility did not report the injury to the Ombudsman, Police, or State department as required by their policy. The incident was also not investigated further to determine the cause of the fall and ensure the resident's safety. The facility's policies on Unusual Occurrence Reporting and Abuse Investigation and Reporting require that such incidents be reported to appropriate agencies within 24 hours and a written report be submitted within 48 hours. However, these procedures were not followed, resulting in a delay of an onsite inspection by the Department to ensure the safety of the residents. The failure to report and investigate the incident promptly had the potential to place residents at further risk for injuries.
Failure to Report Unusual Occurrence and Injury of Unknown Source
Penalty
Summary
The facility failed to implement its policy regarding the reporting of an unusual occurrence and injury of unknown source within 24 hours for Resident 26. Resident 26, who has a history of unspecified type 2 diabetes mellitus, cerebral infarction, and unspecified dementia, was found on the floor in an unwitnessed fall with abrasions on the right eye and knee. Despite the physician ordering a stat x-ray and the resident displaying moderate cognitive impairment, the incident was not reported to the Ombudsman, Police, or State department as required by the facility's policy and procedures. This failure resulted in a delay of an onsite inspection by the State Agency to ensure the safety of the residents. During an interview, RN 2 confirmed that the incident involving Resident 26 was not reported to the appropriate authorities and acknowledged that the facility should have investigated further to rule out potential abuse. The facility's policy mandates that unusual occurrences be reported within 24 hours via telephone to appropriate agencies and a written report be sent within 48 hours. However, this protocol was not followed, leading to a deficiency in the facility's compliance with state and federal regulations.
Failure to Ensure Proper Use of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide preventive care consistent with professional standards of practice to two residents at risk for pressure injuries. Resident 9, who was admitted with severe protein-calorie malnutrition, type 2 diabetes mellitus, and recurrent depressive disorder, had a stage four pressure ulcer. Despite having an order for a low air loss mattress (LALM) to manage the pressure ulcer, the LALM was found turned off during an observation, causing the resident discomfort and potentially exacerbating the pressure injury. The facility's policy indicated that the LALM should be turned on at all times for residents with multiple wounds and high risk for pressure injuries, which was not adhered to in this case. Resident 21, diagnosed with toxic encephalopathy, chronic obstructive pulmonary disease, and muscle wasting, also had a pressure ulcer and was using a pressure-reducing device for the bed. The physician's order specified that the LALM settings should be adjusted according to the resident's weight every shift. However, during an observation, the LALM was set incorrectly for a weight of 105 pounds, while the resident's actual weight was 137 pounds. This incorrect setting was confirmed by a Licensed Vocational Nurse, who acknowledged that the improper setting could delay wound healing and increase the risk of further pressure ulcers. The facility's policy required that specialty beds be obtained and used according to provider orders, which was not followed in this instance.
Failure to Maintain and Improve Range of Motion for Resident
Penalty
Summary
The facility failed to ensure that Resident 190 received appropriate treatment and services to maintain or improve range of motion (ROM) and mobility. Resident 190, who has diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times lying laterally sideways on the bed with both feet hanging off the bottom of the bed. The resident's care plan included interventions to turn and reposition every two hours and as needed, but these interventions were not consistently followed. The resident reported not receiving exercises for his arm and not being repositioned since the morning. Staff interviews revealed that although Resident 190 tended to refuse care and repositioning, these refusals were not documented as required by the facility's policy and procedures for repositioning, which were reviewed on 2/22/2024. Observations and interviews with staff indicated that Resident 190 was not repositioned every two hours as per the care plan and facility policy. Licensed Vocational Nurse 3 and Registered Nurse 1 both acknowledged that Resident 190's refusals to be repositioned were not documented in the turning and reposition logbook. This lack of documentation and adherence to the care plan placed Resident 190 at risk for further ROM decline and contracture. The facility's policy emphasized the importance of repositioning for preventing skin breakdown, promoting circulation, and providing pressure relief, especially for residents who are immobile or dependent on staff for repositioning.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift for three consecutive days. On 3/23/2024, 3/24/2024, and 3/25/2024, only projected hours were posted at Nursing Station 1 instead of the actual hours worked. During interviews, the Director of Infection Preventionist Nurse/Director of Staff and Development (IPN/DSD) confirmed that the facility only posted projected hours and was initially unsure if actual hours should be posted. A review of the facility's policy and procedures indicated that actual hours should be posted daily, but this was not being followed.
Failure to Ensure Proper Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, specifically in the management of medications from the emergency kit (e-kit) and the administration of medications to residents. During an observation of the medication room, it was found that the e-kit medications were opened and unsealed, and the pharmacy log was not properly completed. This led to an inability to determine which medications were used and when the e-kit was opened. The facility's policy required that medications used from the e-kit be recorded and replaced as soon as possible, but this was not followed, potentially leading to a lack of availability of necessary medications during emergencies. Additionally, the facility did not adhere to professional standards of practice for medication administration. A Licensed Vocational Nurse (LVN) was observed crushing multiple medications together, including Apixaban, Proscar, Metoprolol, Aspirin, and Loratadine, which is against the manufacturer's guidelines for Proscar. Crushing medications together can lead to physical and chemical incompatibilities, loss of effectiveness, and worsening of medical conditions. The Director of Nursing (DON) confirmed that the medications should not have been crushed together and that Proscar, in particular, should not be crushed due to its teratogenic properties. Resident 15, who was mildly impaired and dependent on assistance for most activities of daily living, was directly affected by this practice. The resident's medical history included benign prostatic hyperplasia, secondary hypertension, and hyperlipidemia. The facility's policy required that medications be administered safely and as prescribed, with checks to verify the right resident, medication, dosage, time, and method of administration. However, these procedures were not followed, leading to the potential for harm to the resident due to improper medication administration.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement Gradual Dose Reductions (GDR) for two residents, leading to potential overuse of antipsychotic medications. Resident 21, who was diagnosed with schizophrenia, anxiety disorder, and major depressive disorder, was prescribed Haloperidol and Mirtazapine. Despite a recommendation from the Pharmacist Consultant for a GDR, there was no follow-up with the physician to evaluate the necessity of the dose reduction. This oversight was confirmed during an interview with a Registered Nurse, who acknowledged that the GDR recommendations were not followed up with the physician, putting the resident at risk for unnecessary medications and other issues while taking those medications. Similarly, Resident 10, diagnosed with schizophrenia, schizoaffective disorder, and secondary hypertension, was prescribed Clonazepam and Fluphenazine. The Pharmacist Consultant also recommended a GDR for this resident, but again, there was no indication that the physician agreed or disagreed with the recommendation. The facility's policy and procedures require that residents using antipsychotic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, but this was not adhered to in these cases.
Improper Medication Crushing Leading to High Error Rate
Penalty
Summary
The facility failed to ensure that medications were not crushed together during administration, resulting in a medication error rate of 16%, which is significantly higher than the acceptable rate of less than 5%. During an observation, an LVN was seen crushing five different medications together, including Apixaban, Proscar, Metoprolol, Aspirin, and Loratadine, and administering them to a resident. The LVN acknowledged that medications should be crushed separately to ensure proper administration and avoid potential interactions. Additionally, Proscar should not have been crushed as per the manufacturer's guidelines due to its teratogenic properties. The Director of Nursing confirmed the improper practice of crushing medications together and admitted that the medication cart should have had a list of medications that should not be crushed. The facility's policy and procedures require medications to be administered safely and as prescribed, with the individual administering the medication verifying the right resident, medication, dosage, time, and method of administration. The facility's list of medications not to be crushed and the manufacturer's guidelines both indicated that Proscar should not be crushed.
Failure to Dispose of Medication Within Recommended Timeframe
Penalty
Summary
The facility failed to ensure that Resident 34's Levalbuterol hydrochloride (HCL) nebulizer medication was disposed of within two weeks after opening, as per the manufacturer's policy. During an observation and interview with a Licensed Vocational Nurse (LVN), it was noted that the opened foil pouch of Levalbuterol HCL was dated 3/8/2024, which exceeded the two-week usage period. The LVN confirmed that the medication should have been discarded within two weeks of opening the foil pouch, as indicated by the manufacturer's guidelines. This oversight was in direct violation of the facility's policy and procedure on the storage of medications, which mandates that outdated or deteriorated drugs should not be used and must be stored safely and securely. Resident 34, who was admitted with diagnoses including encephalopathy, urinary tract infection, and congestive heart failure, had severe cognitive impairment and required moderate assistance for activities of daily living. The resident's medication order included Levalbuterol HCL inhalation via nebulizer every four hours as needed for conditions such as shortness of breath and wheezing. The failure to dispose of the medication within the recommended timeframe had the potential to compromise the safety and effectiveness of the treatment provided to Resident 34, placing the resident at risk for respiratory difficulties.
Failure to Update Facility Assessment
Penalty
Summary
The facility failed to update the Facility Assessment (FA) annually to include the Activity Director (AD) and Social Service Director (SSD) in the staffing plan. This deficiency was identified during an interview and record review with the Director of Nursing (DON) on 3/25/2024. The FA, reviewed on 2/22/2024, did not list the AD and SSD as part of the staffing plan, which is essential for meeting resident care needs. The DON acknowledged the omission and emphasized the importance of including both AD and SSD in the FA to provide a comprehensive overview of the resources available to residents. The facility's policy and procedures also indicated that the FA should include a detailed review of resources and involve directors from various departments, including social services and activity services.
Failure to Implement Antibiotic Protocol and Monitor Use
Penalty
Summary
The facility failed to implement its protocol for antibiotic use and did not monitor actual antibiotic use for two residents. During an interview and record review with the Infection Preventionist Nurse (IPN), it was confirmed that the antibiotic surveillance log was not initiated for the residents, which should have included details such as the drug name, dose, frequency, and duration of treatment. The IPN acknowledged the importance of having a complete log to track trends and determine the appropriateness of antibiotic orders, which was not done in this case. This failure had the potential to lead to antibiotic resistance in the residents due to unnecessary and inappropriate use of antibiotics. In a separate interview and record review with the Director of Nursing (DON), it was confirmed that there was no tracking log on file for ordered antibiotics. The DON stated that the absence of an antibiotic tracking log could result in the administration of unnecessary antibiotics to residents. The facility's policy and procedures on Antibiotic Stewardship, revised in February 2024, required that complete antibiotic orders include specific elements such as drug name, dose, frequency, duration of treatment, route of administration, and indications for use. These requirements were not met, leading to the identified deficiencies.
Room Size Deficiency
Penalty
Summary
The facility failed to ensure that 10 out of 20 resident rooms met the square footage requirement of 80 square feet per resident. Specifically, rooms 104, 105, 106, 107, 108, 109, 116, 117, 119, and 120 were found to have less than the required space per resident, with each room accommodating three residents but providing only between 66.30 and 74.73 square feet per resident. This deficiency was identified through a review of the Client Accommodation Analysis and was confirmed by observations and interviews with residents and staff, who reported having enough space to move freely and for nursing staff to provide care. Despite the deficiency, no issues or concerns regarding room size were voiced during a resident council meeting, and the facility had submitted a written request for a continued room waiver.
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What surveyors actually found near you
We read the 5,748 citations issued within 25 miles in the last 12 months — including the 42 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Behavioral Health Center | 0.3 mi | ★★★★★ | 16 | 0 |
| Culver West Health Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Mar Vista Country Villa Healthcare & Wellness | 0.6 mi | ★★★★★ | 5 | 0 |
| Marina Pointe Healthcare & Subacute | 1.1 mi | ★★★★★ | 7 | 0 |
| Overland Terrace Healthcare & Wellness Centre, Lp | 1.8 mi | ★★★★★ | 2 | 0 |
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