Woodland Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 7120 Corbin Ave., Reseda, California 91335
- CMS Provider Number
- 056066
- Inspections on file
- 95
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Woodland Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, intact cognition, and independence in ADLs had inconsistent body weights documented in the medical record. A restorative nursing attendant recorded the resident’s weight as 148 lbs, but the ADON later entered 158 lbs on the weight summary instead of the correctly obtained value. A subsequent weighing by another RNA showed 143 lbs. The ADON and DON acknowledged that the 158-lb entry was incorrect and that the resident’s weight should have been documented as 148 lbs, contrary to the facility’s policy requiring objective, complete, and accurate charting.
A resident with multiple medical conditions experienced a change in condition involving eye symptoms after returning from being out of the facility, and although an LVN documented an initial assessment, there was no documented reassessment on the following day shift despite facility practice to monitor and reassess for 72 hours after a COC. In a separate episode, the same resident showed increased sleepiness and an altered routine, leading an MD to order stat labs including CBC, CMP, Keppra level, UA, and urine C&S; the resident refused to provide a urine specimen, the UA and C&S were not completed, and while the MD was informed of the blood test results, there was no documentation that the MD was notified of the urine refusal, contrary to facility expectations and policy requiring practitioner notification of treatment refusals.
A resident with multiple medical conditions, including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and HTN, returned from being out of the facility with noted left eye changes, including reported drooping and unequal pupils. An LVN assessed the resident, documented eye findings, and recorded on a Change of Condition form that the MD was notified, but entered an incorrect notification time instead of the actual time the MD was called. During interview and record review, the DON confirmed the inaccuracy and that documentation must be timely and accurate per facility policies on change in condition notification and charting.
A resident with intact cognition, independent ADLs, and multiple diagnoses, including Parkinson’s disease and bipolar disorder, had a care plan intervention requiring licensed nurses to discuss medications with the resident and validate and initial medication sheets for accuracy due to concerns about the POA denying or forgetting medication-related requests. The resident had a weekly pyridoxine HCL order, and the MAR showed scheduled and administered doses, while a separate facility-created medication list used to validate administration times showed pyridoxine checked as given on a specific day and time. During interview, an LVN admitted he had mistakenly documented pyridoxine as administered on the validation list even though the resident did not receive the dose, and the DON confirmed that this list was intended to verify that medications were given at the correct scheduled times, demonstrating a failure to accurately implement the care-planned medication validation process.
A resident with fractures and neuropathic pain did not receive methocarbamol and gabapentin at the prescribed times, with doses given outside the facility’s one-hour administration window and too close together. A lidocaine 4% patch was found still in place when it should have been removed by the prior shift, and the resident then refused a new patch. In addition, the admitting RN transcribed a hospital order for a lidocaine patch from twice daily to once daily without clear verification, while the physician later stated the frequency had not been changed and that hospital discharge instructions should have been followed.
A resident with Parkinson’s disease, hypotension, and bipolar disorder, who was cognitively intact and independent in ADLs, had a urology appointment cancelled at the request of the responsible party, which was documented by an RN in the progress notes and on the communication log. However, the oncoming nursing staff did not follow up on this request, did not notify Social Services, and did not cancel the arranged transportation. As a result, the resident was transported to the clinic for a cancelled appointment and returned without being seen.
A nurse failed to accurately document blood pressure readings for a resident with severe cognitive impairment and multiple cardiac diagnoses, instead copying earlier readings into the MAR before administering antihypertensive medication. The nurse admitted to falsifying documentation due to workload, and the DON confirmed this violated facility policy requiring real-time, accurate charting.
A resident with Parkinson's disease and hypotension did not receive a prescribed dose of midodrine, despite their blood pressure being within the physician-ordered parameters. An LVN withheld the medication out of concern for increased blood pressure, contrary to the order and facility policy, resulting in a failure to provide care according to professional standards.
A bottle of ketoconazole 2% shampoo, prescribed for a resident with seborrheic dermatitis, was found unattended on top of a toilet in a shared restroom instead of being secured in a locked treatment cart as required by facility policy. The treatment nurse confirmed that all medications should be stored securely, and the facility's policy mandates locked storage accessible only to authorized staff.
A resident was readmitted with multiple serious diagnoses and required significant assistance with daily activities, but the attending physician did not complete and document the required H&P assessment within 72 hours. The DON confirmed the delay, and the NP cited workload issues as the reason for not completing the H&P on time, contrary to facility policy requiring timely documentation.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a physician-ordered nutritional supplement drink at breakfast and lunch, as required by their care plan and nutritional assessment. Staff interviews confirmed the supplement was not given, and the DON acknowledged it should have been provided according to orders and facility policy.
Two residents with severe cognitive impairment were not provided with meals that matched their documented food preferences, despite these preferences being clearly indicated on their dietary profiles and meal tickets. One resident did not receive mashed potatoes as preferred, and another did not receive coffee with lunch. Staff interviews and policy reviews confirmed that these omissions were inconsistent with facility procedures requiring adherence to resident meal preferences.
A resident did not receive prescribed Systane night ophthalmic gel for two nights because the medication was not delivered, and the LPN did not notify the physician about the missed doses. The DON confirmed that facility policy requires physician notification when medications are unavailable, but this was not done in this case.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident's clinical record was found to be incomplete due to missing documentation of scheduled Restorative Nurse Aide (RNA) treatments for active range of motion and ambulation. On several occasions, RNA staff did not sign or indicate whether the treatments were provided or refused, despite facility policy requiring such documentation. Interviews with the DSD and DON confirmed that staff should have recorded this information to ensure accurate records.
A resident with significant medical needs was not given scheduled oxycodone-acetaminophen for pain management as ordered by the physician. Although an LVN documented that the medication was administered, subsequent review showed the medication was not dispensed and the documentation was inaccurate. The resident reported not receiving the prescribed pain medication and only being offered Tylenol, which was ineffective.
A resident with multiple medical conditions did not receive a scheduled dose of oxycodone-acetaminophen as ordered by the physician. An LVN documented the administration of the medication in the MAR, but a review of medication records and interviews confirmed that the dose was not given. The resident reported not receiving effective pain relief and left the facility against medical advice. The facility's policy required accurate medication administration and documentation, which was not followed.
A resident with multiple medical conditions was prescribed oxycodone-acetaminophen for pain, but an LVN documented its administration in the MAR when it was not actually given. The resident reported not receiving the medication, and a review of medication records and the bubble pack confirmed that no doses were dispensed. The LVN later admitted to the documentation error, which resulted in an inaccurate medical record.
A resident with documented gluten and lactose allergies was served cream of wheat for breakfast, despite clear dietary orders and care plans specifying a gluten-free, lactose-free diet. The correct gluten-free substitute was not available in stock, and staff lacked adequate training and knowledge about gluten-containing foods. The meal ticket did not specify the appropriate substitute, and the food service manager did not verify the tray for dietary compliance before delivery, resulting in the resident being provided with an inappropriate meal.
Three residents with significant medical and cognitive needs were found without accessible call lights while in bed, including one with dementia and another with hemiplegia. In each case, the call light was either under the bed, dangling out of reach, or on the floor, and staff confirmed the devices were not positioned for resident use as required by facility policy.
Several residents did not have comprehensive, person-centered care plans addressing the use of bed siderails or contact isolation precautions, despite physician orders and facility policy requiring such plans. Staff and leadership confirmed that care plans lacked necessary interventions and guidance, and observations showed residents using siderails or under isolation without appropriate care planning.
Licensed nurses failed to rotate insulin injection sites for three residents with diabetes, administering repeated injections in the same area despite physician orders and facility policy requiring site rotation. This deficiency was confirmed through record review and staff interviews.
A resident with an unstageable pressure ulcer did not receive a required weekly wound assessment and missed a prescribed daily wound treatment, as confirmed by review of records and staff interviews. The facility failed to follow physician orders and its own policy for pressure ulcer management, resulting in incomplete monitoring and care.
Two residents were placed at increased risk for injury when one was left with an exposed, reachable cable above the bed despite cognitive impairment, and another did not have required landing pads on both sides of the bed as ordered after a fall. Staff and management acknowledged these hazards, which were not consistent with facility safety and fall management policies.
A nurse failed to document the administration of controlled medications on the required accountability logs after giving doses to three residents with chronic pain, neuropathy, and anxiety. This resulted in discrepancies between the medication bubble packs and the controlled drug records for hydrocodone-acetaminophen, pregabalin, and lorazepam, as discovered during a medication cart audit. The DON confirmed that facility policy was not followed, as immediate documentation is required when administering controlled substances.
Two residents experienced medication errors when nurses failed to administer medications as ordered—one received a lidocaine patch to only one wrist instead of both, and another did not receive a prescribed Omega 3 supplement. These errors resulted in a medication error rate above 5%, exceeding facility policy and standards.
Surveyors found that staff failed to rotate insulin injection sites for three residents and did not follow physician-ordered hold parameters for midodrine in another resident. These actions were confirmed through MAR review and staff interviews, with facility policy and physician orders clearly requiring site rotation and adherence to medication parameters. The residents involved had complex medical conditions and required staff assistance for daily care.
A resident with a documented gluten allergy and physician orders for a gluten-free diet was served cream of wheat due to a lack of staff training and competency evaluation on gluten-free diets. Dietary staff were unaware of proper substitutions and had not received specific training, resulting in repeated exposure to gluten-containing foods despite clear documentation of the resident's allergies and dietary needs.
A resident with moderate cognitive impairment and a history of paraplegia was served apple juice despite their meal tray ticket indicating an apple juice allergy, which had previously been removed from their records. Due to a system glitch and lack of proper tray verification by dietary and nursing staff, the outdated allergy information remained on the tray ticket, and the facility's policy for checking trays was not followed.
Surveyors found that food items, including pineapple Bavarian cream, cheese enchiladas, and pureed vegetables, were not prepared or served according to required temperature and consistency standards. Cold desserts were served above safe temperatures, enchiladas were dry and lacked sauce, and pureed vegetables were runny and did not hold their shape, all contrary to facility policies and recipes. These deficiencies were confirmed by dietary staff and placed many residents at risk of inadequate nutrition.
The facility did not prepare pureed foods according to required consistency standards, resulting in grainy cheese enchiladas, rice with visible grains, and runny vegetables with liquid separation. These deficiencies were confirmed by dietary staff and did not meet IDDSI Level 4 guidelines, potentially affecting 11 residents on pureed diets.
Surveyors identified multiple deficiencies in food storage and preparation, including corroded racks, cracked meal trays, and unclean kitchen equipment. Dietary staff were observed wearing prohibited jewelry during food handling, and a resident's leftover food from outside was not properly labeled with an identifier or use-by date. These actions were confirmed by staff interviews and were not in compliance with facility policies or the Food Code.
Improper disposal of garbage and refuse was observed, with soiled gloves, an empty spray bottle, plastic, and other trash found on the ground, and one dumpster contaminated with dried food spills and dirt. Both the Dietary Supervisor and Environmental Services Supervisor confirmed these unsanitary conditions, which had the potential to attract pests and spread infection to most residents, in violation of facility policy and the Food Code.
Surveyors found that a resident's nasal cannula oxygen tubing was left on the floor, leading to contamination, and that two residents' urinals were not labeled with identifiers, increasing the risk of cross-contamination. The Infection Preventionist and staff confirmed these lapses, and the facility lacked a specific policy for labeling urinals, despite having a general standard precautions policy.
A resident admitted for palliative care with end stage renal disease had a silver bracelet documented on admission. After the resident's death, the facility was unable to account for or return the bracelet to the resident's representative, as confirmed by the Social Services Director and facility records. This failure violated the facility's policy on safeguarding and releasing personal belongings.
A nurse administered several medications to a resident with multiple chronic conditions and moderate cognitive impairment without informing the resident of the medication names or their purposes, as required by facility policy. The nurse later acknowledged the omission, and the DON confirmed that this action did not align with resident rights policies.
A resident with intact cognitive skills and multiple medical diagnoses was not included in the quarterly IDT care conference for developing an individualized care plan. The resident was unaware of discharge plans and expressed frustration about not being consulted, while facility records and staff confirmed the absence of resident or representative participation, contrary to facility policy.
Two residents did not have their care plans updated after significant changes in their conditions. One resident's fall and subsequent new interventions were not reflected in the care plan, and another resident's care plan continued to list oxygen therapy after the physician order for oxygen was discontinued. Staff confirmed that care plans were not reviewed or revised as required by facility policy.
A resident dependent on staff for ADLs, including dressing and personal hygiene due to dementia and other conditions, was not provided with necessary care. The resident's clothing was not changed for three days, as shown by an old food stain, and oral hygiene was neglected after meals, leaving residue on the teeth. Staff and family confirmed these lapses, which were inconsistent with facility policies requiring daily assistance with grooming and hygiene.
A resident with an indwelling catheter did not receive daily catheter care, infection monitoring, or skin assessments as required by their care plan. Staff failed to provide and document these interventions, despite the resident's dependence on staff for personal hygiene and the facility's policy emphasizing the importance of catheter care.
The facility failed to obtain physician orders before administering oxygen to two residents and did not label oxygen tubing with the date of last change as required by policy. One resident with COPD continued to receive oxygen after the order was discontinued, and another received oxygen for shortness of breath without a current order, with unlabeled tubing remaining in the room. Staff confirmed these deficiencies during interviews and record reviews.
A resident's opened budesonide inhalation solution foil pouch was found in a medication cart without a date label, and five ampules were stored outside the protective pouch. An LVN and the DON confirmed that facility policy and manufacturer guidelines require labeling with the date of opening and that ampules stored outside the pouch expire in two weeks. The lack of labeling meant the expiration date could not be determined, resulting in potentially expired medication being available for use.
A resident with multiple medical conditions reported missing money after a hospital stay, but the facility did not notify the required authorities within the mandated timeframe. Although an internal investigation was conducted and the allegation was unsubstantiated, the administrator confirmed that notifications to the State Survey Agency, ombudsman, and law enforcement were not made as required by facility policy.
A resident with multiple medical conditions and intact cognition reported missing money after a hospital stay. The facility initiated a theft/loss report and conducted some staff interviews and searches, but did not notify law enforcement or interview all relevant staff. Documentation was inconsistent regarding the resident's funds, and a staff member found a wallet with cash but did not secure it. The facility did not follow up with the resident or report the allegation to authorities, failing to meet its own policy for investigating theft or misappropriation.
A resident with severe cognitive impairment and Alzheimer's Disease was discharged to an assisted living facility, but the MDS assessment was incorrectly coded to indicate discharge to a hospital. Multiple records, including the admission record, physician's orders, and discharge plan, confirmed the actual discharge destination, and the MDS Coordinator acknowledged the error during review.
A facility failed to provide complete medication reconciliation and necessary education at discharge for three residents. Discharge documentation lacked details on medications and quantities provided, and there was no communication about monitoring for bleeding for a resident on apixaban and Plavix. The facility's discharge policy was not followed, leading to incomplete documentation and inadequate post-discharge care instructions.
A CNA failed to wear PPE while in the room of a resident on contact isolation for C-diff, despite facility protocols and signage indicating the requirement. The resident had multiple diagnoses, including dementia and a positive C-diff test. Interviews with nursing leadership confirmed the breach in infection control procedures.
The facility failed to provide tissue boxes for two residents, impacting their ability to maintain personal hygiene. One resident with chronic kidney disease and another with cardiomegaly were observed without tissues, despite their care plans emphasizing independence and the facility's policy to supply such items. Staff confirmed the absence of tissues, which should have been replenished automatically.
A resident's grievance about late-night disturbances by a roommate and her son was not documented or logged by the facility, despite being reported during a staff meeting. The Social Services Designee acknowledged the oversight, citing time constraints, which led to non-compliance with the facility's grievance policy requiring documentation and timely resolution.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was admitted to the facility. Following an allegation of financial abuse, no specific care plan was developed to address this issue, despite facility policy requiring individualized care plans. Interviews with staff confirmed the oversight, highlighting a deficiency in care planning.
Inaccurate Documentation of Resident Body Weight
Penalty
Summary
The facility failed to accurately document a resident’s body weight in the medical record. The resident was originally admitted with diagnoses including Parkinson’s disease, dysphagia, dementia, bipolar disorder, and hypotension, and had intact cognition and independence with ADLs per the MDS. A weight summary for the resident from early January to early March showed weights of 159 lbs on two occasions and 158 lbs on a later date. However, a separate list of resident weights obtained by a restorative nursing attendant on February 28 documented the resident’s weight as 148 lbs. On March 5, another restorative nursing attendant weighed the resident and obtained a weight of 143 lbs. During a subsequent review and interview, the ADON confirmed that the weight summary entry of 158 lbs on March 3 had been entered by the ADON and was incorrect, and that the resident’s weight should have been documented as 148 lbs based on the February 28 measurement. The DON also stated that the resident’s body weight should have been accurately documented in the medical record to reflect the correct weight of 148 lbs. This inaccurate documentation was inconsistent with the facility’s charting and documentation policy, which requires that medical records be objective, complete, and accurate and facilitate communication about the resident’s condition and response to care.
Failure to Reassess After Change in Condition and Notify MD of Lab Refusal
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for one resident following documented changes in condition. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and hypertension, returned to the facility on 4/13/2025 at 4:30 p.m. with a reported change in condition involving left eye drooping and unequal pupils. A Change of Condition (COC) form documented that an LVN assessed the resident and noted no drooping, the left eye closed but able to open without difficulty, and redness of the left eye. However, review of the nursing progress notes for the following day shift on 4/14/2025 showed no documentation of a required reassessment after this change in condition, despite facility practice that residents are to be monitored for 72 hours with reassessments each shift following a COC. A second deficiency occurred when the facility failed to notify the resident’s physician that ordered laboratory tests were not fully completed due to the resident’s refusal to provide a urine specimen. On 9/18/2025, a COC form documented that the resident exhibited increased sleepiness and an altered routine, prompting notification of the physician, who ordered stat labs including a CBC, CMP, Keppra level, UA, and urine C&S. The laboratory requisition form for that date indicated the resident refused to provide a urine sample, and therefore the UA and C&S were not submitted for analysis. Nursing progress notes documented that the physician was informed of the CBC, CMP, and Keppra results, but there was no documentation that the physician was notified of the resident’s refusal to provide the urine specimen or that the UA and C&S were not completed. Interviews with facility staff confirmed these lapses. An LVN stated that after a COC, residents are to be monitored for three days with reassessments each shift, and acknowledged there was no documented reassessment on the day shift following the 4/13/2025 COC. The DON similarly stated that the standard of practice is to complete and document reassessments on each nursing shift after a COC and to notify the physician of any changes in condition, and confirmed there was no documented reassessment on 4/14/2025. The DON also stated that when a physician orders laboratory tests, the physician should be notified of the results, including any resident refusal to provide a specimen, and acknowledged there was no documentation that the physician was informed of the resident’s refusal to provide a urine sample on 9/18/2025. The facility’s policy on requesting, refusing, and/or discontinuing care or treatment indicated that the healthcare practitioner must be notified of treatment refusals in a timeframe determined by the resident’s condition and potential serious consequences of the request.
Inaccurate MD Notification Time Documented on Change of Condition Form
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation on a Change of Condition (COC) form for one resident. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and HTN, returned to the facility on 4/13/2025 at 4:30 p.m. after being out of the facility. The COC form for that date documented that the resident had left eye drooping and unequal pupils. An assessment by LVN 1 indicated no drooping was observed, the resident’s left eye was closed but could be opened without difficulty, and redness of the left eye was noted. LVN 1 documented on the COC form that the resident’s MD was notified of the change of condition and recorded the notification date and time as 4/13/2025 at midnight. During an interview and concurrent record review on 1/29/2026 at 3:05 p.m., the DON confirmed that the COC form showed left eye drooping and unequal pupils and acknowledged that the time documented for MD notification was not correct. The DON stated that LVN 1 should have documented the actual time the MD was called and notified of the change of condition on the COC form and that information on the COC form must be timely and accurate. Review of the facility’s policies on Change in Condition: Notification and Charting and Documentation showed that the facility requires residents, family/legal representatives, and physicians to be informed of changes in condition, and that all changes in a resident’s medical, physical, functional, or psychosocial condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team.
Failure to Accurately Implement Care-Planned Medication Validation and Documentation
Penalty
Summary
The deficiency involved the facility’s failure to implement a resident’s comprehensive care plan related to medication validation and documentation. The resident, who had intact cognition and was independent with ADLs, had diagnoses including Parkinson’s disease, hypotension, and bipolar disorder, and an order for pyridoxine HCL 25 mg, 0.5 tablet by mouth once every seven days for vitamin B6 deficiency, with monitoring for neurologic symptoms of excess vitamin B6. The resident’s care plan, initiated earlier and last revised in August, identified that the resident’s POA had episodes of denying or forgetting requests made, including for medications or supplements, and included an intervention for licensed nurses to discuss medications with the resident and to validate and initial in the medication sheets the medications and times of administration. Record review showed that the MAR documented pyridoxine as scheduled and administered on four Thursdays in December, and a separate medication list created by the facility to validate that the resident received medications at scheduled times showed pyridoxine 25 mg, 0.5 tablet every seven days on Thursday at 9 a.m., marked with a check on a specific December date. During interview and concurrent record review, the LVN acknowledged that he had mistakenly documented on the medication list that pyridoxine was administered on that date, while confirming the resident did not actually receive the medication. The DON confirmed that the medication list was intended to validate that medications were given at scheduled times and that the LVN had checked pyridoxine as administered on a Wednesday, although it was ordered for weekly Thursday administration, and that this process was part of the care-planned intervention for validating medications and administration times.
Failure to Administer and Manage Pain Medications per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders for one resident with multiple right rib fractures, a lumbar wedge compression fracture, and a history of falls. The resident was cognitively intact and required moderate assistance with several ADLs. Physician orders on admission included methocarbamol 500 mg PO three times daily for muscle spasm, gabapentin 100 mg PO three times daily for neuropathy, and a lidocaine 4% patch applied topically to the right chest area once daily for pain management with removal per schedule. Medication Administration Record (MAR) audit data showed that on one date, the 9 a.m. doses of methocarbamol and gabapentin were not administered until 12:07 p.m., and the 1 p.m. doses were not administered until 2:42 p.m., outside the facility’s stated one-hour before/after administration window. The LVN who passed these medications acknowledged being late with the medication pass and confirmed that some medications were given outside the time frame, resulting in the two scheduled doses of both methocarbamol and gabapentin being administered too close together. The DON confirmed that these administration times were not timely per the physician’s orders and that the doses were administered too close together. The facility also failed to ensure proper management of the resident’s lidocaine 4% patch. One LVN reported finding an old lidocaine patch still in place on the resident’s lower lumbar area that should have been removed by the prior 3 p.m.–11 p.m. shift nurse, and documented that the resident was upset and refused a new patch. The DON stated the patch was supposed to be removed daily at 9 p.m. by the evening shift and referenced hospital discharge instructions indicating the patch should be removed after 8–12 hours. Additionally, hospital discharge instructions directed application of one lidocaine 4% patch to the affected area twice daily for seven days, but the admitting RN carried over the order as once daily and could not recall how the order was verified with the physician. The primary care physician later stated he did not change the lidocaine patch frequency from twice daily to once daily and that the facility should have followed the hospital discharge instructions.
Failure to Cancel Transportation After Appointment Cancellation Request
Penalty
Summary
The deficiency involves the facility’s failure to follow up on and cancel a resident’s transportation after the resident’s responsible party requested cancellation of a scheduled urology appointment. The resident, who had diagnoses including Parkinson’s disease, hypotension, and bipolar disorder, was cognitively intact and independent in ADLs per the MDS. On the night prior to the appointment, a nursing progress note documented that the responsible party requested cancellation of the urology appointment. RN 2 also entered this request into the facility’s communication log for the morning staff to follow up, but did not provide a verbal handoff to the next shift. Despite this documented request and communication log entry, the morning nurse did not follow up to cancel the resident’s transportation. As a result, the resident left the facility for the urology appointment and traveled to the clinic, only to find that the appointment had been cancelled. The resident then returned to the facility without being seen by the urologist. The DON and Social Services Director confirmed that nursing staff did not notify Social Services to address the cancelled appointment and that there was no documentation that transportation had been cancelled, leading to the unnecessary transport.
Falsification of Blood Pressure Documentation in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident by not ensuring that a Licensed Vocational Nurse (LVN) documented actual blood pressure readings prior to administering antihypertensive medication. The resident in question had a history of heart failure, cardiomegaly, and essential hypertension, and required substantial assistance with daily activities due to severe cognitive impairment. According to the resident's medication orders, blood pressure was to be checked and documented before administering diltiazem, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. On multiple occasions, the LVN documented blood pressure readings in the Medication Administration Record (MAR) at 1 p.m. that were identical to those recorded at 9 a.m. on the same days, rather than recording the actual readings taken at the later time. During interviews, the LVN admitted to copying the earlier readings instead of documenting the true values, citing a fast-paced work environment and a high resident load as reasons for this action. The Director of Nursing confirmed that this constituted falsification of documentation, as staff are required to document blood pressure readings in real time and accurately reflect the resident's condition. Facility policies reviewed also emphasized the importance of timely, accurate, and comprehensive documentation in the medical record.
Failure to Administer Prescribed Medication per Physician Order
Penalty
Summary
The facility failed to ensure that a resident received pharmaceutical services in accordance with professional standards of practice by not administering midodrine as prescribed by the physician. The resident, who had diagnoses including Parkinson's disease and hypotension, had a physician's order for midodrine hydrochloride 10 mg by mouth three times daily, to be held only if systolic blood pressure (SBP) exceeded 150. On the date in question, the resident's blood pressure was 150/89, which was within the prescribed parameters for administration, yet the medication was not given. During interviews and record reviews, it was confirmed that the medication was withheld by an LVN who was concerned about the resident's blood pressure increasing, despite the physician's order specifying when to hold the medication. The facility's policy required medications to be administered as prescribed and in a timely manner. The omission of the medication was acknowledged by both the MDS nurse and the LVN, who stated that the medication should have been administered according to the physician's order.
Medication Storage Lapse: Topical Medication Left Unsecured
Penalty
Summary
A bottle of ketoconazole 2% shampoo, prescribed for a resident with seborrheic dermatitis, was found unattended on top of a toilet in a shared restroom. The medication was intended for topical use on the scalp and was ordered to be applied on specific days. Facility policy requires all drugs and biologicals to be stored in locked compartments, with access limited to authorized personnel. During an observation, the shampoo was not secured in the treatment cart as required, but instead left in a location accessible to others. The resident involved had intact cognition and was independent with personal care tasks, including hygiene and toileting. The treatment nurse confirmed during an interview that the medication should have been stored in the treatment cart for safety, in accordance with facility policy. The facility's policy and procedure on medication storage, reviewed earlier in the year, specifies that all medications must be stored securely and only accessible to authorized staff. The failure to secure the ketoconazole shampoo constituted a breach of these requirements.
Delayed Physician H&P Documentation After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician completed and documented a History and Physical (H&P) assessment within 72 hours following the resident's readmission. Specifically, the medical record review showed that the resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, did not have an H&P completed until six days after readmission. The resident's Minimum Data Set indicated severely impaired cognition and a need for substantial to maximal assistance with daily activities. Interviews with the DON confirmed that the H&P was not completed within the required timeframe, and the Nurse Practitioner acknowledged being behind on documentation due to a high workload, resulting in delayed completion and signing of the H&P. Facility policies reviewed indicated that timely documentation and physician visits are required to ensure proper care coordination and communication among the interdisciplinary team, but these were not followed in this instance.
Failure to Provide Ordered Nutritional Supplement Drink
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including toxic encephalopathy, sepsis, and pneumonia, was readmitted to the facility and had physician orders for a regular, pureed diet with thin consistency, as well as a nutritional supplement drink to be provided with breakfast and lunch. The resident's care plan and nutritional assessment both specified the need for the supplement drink twice daily to provide additional calories and protein. However, during an observation of the resident's lunch, the nutritional supplement drink was not present on the meal tray. Interviews with dietary and nursing staff revealed that the kitchen does not provide the supplement drinks, and it is the responsibility of nursing staff to administer them. Both the certified nursing assistant and restorative nursing assistant who assisted the resident with meals confirmed that the supplement drink was not provided at breakfast or lunch. The DON acknowledged that the supplement should have been given as per the physician's order. The facility's policy states that therapeutic diets are to be provided according to physician orders and care plans.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of two residents, as identified through observation, interview, and record review. One resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, had a severely impaired cognitive status and required substantial assistance with eating. The resident's dietary profile indicated a preference for mashed potatoes at lunch and dinner, and this preference was noted on the meal ticket. However, during a lunch observation, the resident was not served mashed potatoes as indicated, and the Assistant Dietary Supervisor confirmed the omission. Another resident, admitted with encephalopathy, dysphagia, and Alzheimer's disease, also had severe cognitive impairment and required assistance with eating. This resident's dietary profile specified a preference for coffee with all meals, and the meal ticket for lunch included coffee. During observation, the resident's lunch tray did not include coffee, and both the resident and staff confirmed the omission during interviews. The Director of Nursing and Registered Dietician both acknowledged the importance of following meal tickets and resident preferences to ensure adequate nutritional intake. A review of the facility's policies indicated that the dietary department is responsible for providing meals consistent with residents' preferences as documented on tray cards and that therapeutic diets should align with the resident's goals and preferences. Despite these policies, the facility did not follow the documented preferences for the two residents, resulting in the identified deficiencies.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Systane night ophthalmic gel, was not available and therefore not administered for two consecutive days. The resident, who had diagnoses including Parkinson's disease, hypotension, and bipolar disorder, was cognitively intact and independent in activities of daily living. The medication was ordered to be instilled in both eyes at bedtime for dry eyes, but the Medication Administration Record showed it was not given on two specified dates due to the medication not being delivered. During interviews and record reviews, the Licensed Vocational Nurse confirmed that the medication was unavailable and had not been administered, and also acknowledged that the resident's physician had not been informed of the missed doses. The Director of Nursing stated that facility policy requires nurses to notify physicians when medications are not available, as this could affect the resident's plan of care. The facility's policy on physician notification was reviewed and supported this requirement.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Document Restorative Nursing Treatments in Resident Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting the delivery of Restorative Nurse Aide (RNA) treatments. Specifically, the Restorative Nursing Records for the resident showed missing signatures and no indication of whether scheduled RNA treatments for upper extremity active range of motion and ambulation with an assistive device were provided or refused on multiple dates. The lack of documentation occurred despite the resident having diagnoses including Parkinson's disease, acute respiratory failure with hypoxia, and dysphagia, and being assessed as having intact cognition and independence in activities of daily living. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that RNA staff were expected to sign or document on the Restorative Nursing Record if the resident received or refused treatment, or if the resident was unavailable. The facility's policy required that documentation related to physician orders be maintained in the resident's medical record, with current month's administration records kept in the appropriate binders. The failure to document RNA treatments as required led to incomplete clinical records for the resident.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was not administered his scheduled pain medication as ordered by his physician. The physician's order specified that the resident should receive oxycodone-acetaminophen 7.5-325 mg orally three times a day for pain management. Review of the Medication Administration Record (MAR) indicated that a Licensed Vocational Nurse (LVN) documented administration of the medication on the morning following admission. However, further investigation revealed that the medication was not actually given. The resident's medication bubble pack remained intact with all 30 tablets present, and the controlled drug record confirmed that none of the prescribed doses had been dispensed. The LVN responsible for the resident's care admitted during an interview that she did not administer the medication and had mistakenly documented its administration in the MAR while in a rush. The resident later reported that he did not receive his prescribed pain medication and was only offered Tylenol, which he stated was ineffective for his pain. Facility leadership confirmed that the medication was not administered as ordered and that the documentation in the MAR was inaccurate. The facility's pain management policy required daily assessment and documentation of pain interventions, but in this instance, the resident did not receive the scheduled pain medication, and the documentation did not reflect the actual care provided.
Failure to Administer and Accurately Document Scheduled Pain Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer a prescribed dose of oxycodone-acetaminophen 7.5-325 mg to a resident at the scheduled time, as ordered by the physician. The resident, who had been admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was alert, oriented, and able to communicate needs. The physician's order specified that the pain medication should be given three times daily for pain management. Despite the order, the medication was not administered to the resident on the morning in question. The Medication Administration Record (MAR) incorrectly indicated that the dose had been given, as the LVN documented administration without actually providing the medication. This was later confirmed through interviews and a review of the resident's medication bubble pack and controlled drug record, both of which showed that the medication remained untouched and the count was intact. The resident later reported not receiving any pain medication other than Tylenol, which was ineffective for his pain, and subsequently left the facility against medical advice. The LVN acknowledged the documentation error, stating it was made in haste and that the medication had not been administered. The facility's policy required accurate and timely documentation of medication administration, which was not followed in this instance.
Inaccurate Medication Administration Documentation by LVN
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN 3) inaccurately documented the administration of a prescribed pain medication, oxycodone-acetaminophen, to a resident. The resident, who was admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was ordered to receive oxycodone-acetaminophen 7.5-325 mg three times daily for pain management. The Medication Administration Record (MAR) indicated that the medication was given at 6:00 a.m. on 6/14/2025. However, upon review, it was found that the resident did not receive the medication as documented. The resident reported not receiving any pain medication except Tylenol, which was ineffective for his pain, and stated he left the facility the morning after admission due to lack of pain management and other comfort issues. Further investigation by nursing staff confirmed that the bubble pack containing the prescribed oxycodone-acetaminophen remained intact with all 30 tablets present, and the controlled drug record also showed no doses had been dispensed. There were no doses available in the emergency medication kit either. During interviews, LVN 3 admitted to mistakenly documenting the administration of the medication when it had not been given, attributing the error to being rushed while tending to another resident. The Director of Nursing confirmed that the documentation was inaccurate and did not reflect the actual care provided. Facility policies require accurate and timely documentation of medication administration, and the failure to do so resulted in an inaccurate medical record for the resident.
Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Food Allergies
Penalty
Summary
A resident with documented allergies to gluten and lactose was served cream of wheat for breakfast, despite multiple records indicating these allergies. The resident's care plan, physician's orders, allergy list, dietary profile, and other medical documentation all specified the need for a gluten-free and lactose-free diet. The resident's meal ticket did indicate a gluten restriction, but the actual food provided did not comply, and the meal ticket did not specify the correct gluten-free substitute (cream of rice). The resident reported previous instances of being served foods containing gluten and stated that staff had been informed of these allergies. The dietary staff prepared only oatmeal and cream of wheat for breakfast, and cream of rice, the appropriate substitute, was not available in stock. Staff responsible for preparing and checking trays were either unaware that cream of wheat contained gluten or had been incorrectly informed that it was safe for gluten-free diets. The kitchen staff had not received training on gluten-free diets, and the facility's software failed to update the meal ticket to reflect the resident's dietary needs. The food service manager or supervisor did not check the resident's tray for the correct diet before it was delivered, as required by facility policy. Interviews with staff revealed gaps in knowledge and communication regarding food allergies and dietary restrictions. The licensed nurse who checked the tray was not able to accurately identify whether the hot cereal was gluten-free and relied on incomplete information from the meal ticket. The dietary aide responsible for tray accuracy had been told by a previous supervisor that cream of wheat was acceptable for gluten-free diets, leading to repeated errors. The facility's purchasing records showed that cream of rice had not been restocked in a timely manner, further contributing to the deficiency.
Removal Plan
- The DON immediately assessed Resident 71 for any adverse reaction and there were none noted.
- The facility notified Resident 71's attending physician and Resident 71's family of the incident of giving food containing allergies. The attending physician did not give any new orders.
- The Minimum Data Set Coordinator 1 (MDSC 1) updated Resident 71's allergy Care Plan to remove gluten allergy and Resident 71's nutrition risk Care Plan to reflect gluten intolerance prior to a diagnostic test for allergies.
- The Registered Dietitian (RD) evaluated Resident 71 and updated food preferences, reviewed allergies and food intolerances, and completed a nutritional assessment.
- The Director of Staff Development (DSD) provided one-on-one in-service training to Licensed Vocational Nurse 3 (LVN 3, who checked Resident 71's breakfast prior to serving) to ensure: a) Identification of food allergies using the daily Allergy Report provided by DON and/or designee. The daily Allergy Report can be found in a special needs binder located at each nursing station and dining room. b) Prior to tray passing to residents during mealtimes, a licensed nurse will check all trays for accuracy of meal ticket and physician diet orders against what is on the residents' meal tray using the diet report. c) Prior to passing the meal trays to the residents during mealtimes, a licensed nurse will check the diet type report and the meal ticket on each tray against the food on the resident's meal tray. d) Prior to tray passing to residents during mealtime, a licensed nurse will check all the trays to ensure any resident with a gluten allergy is not served unless food item on food tray is labeled gluten free.
- The DON, the DSD, the RD, the Dietary Supervisor (DS) initiated an in-service to staff (including RNs, LVNs, CNAs, Rehabilitation Therapists, the Dietary Manager, cooks, tray line staff, dishwashers, Dietary Preparation staff, and Department Heads) about identification of food allergies using the daily Allergy Report, 2 licensed nurse will check all the trays to ensure meal ticket, physicians orders and Diet Type Report are accurate against resident's food trays. The in-service also included checking all the trays to ensure all trays are checked for gluten allergies and not served foods containing gluten. Snacks for residents on gluten free diet will be labeled gluten free. A licensed nurse will check the diet type report, snacks label and food to ensure accuracy before serving it to the residents.
- The DS completed an in-service to the dietary staff (Dietary Manager, cooks, tray line staff, dishwashers, and dietary preparation staff) related to food allergy, labeling of gluten-free food items, and ensuring all trays are checked accurately to ensure residents are not served a food item they are allergic prior to trays being sent out of the kitchen. Tray line staff will refer to Diet Manual for Guidance on alternatives for residents on gluten restricted diet/gluten allergy/intolerance. Staff that have not yet been in-serviced (those on vacation and per diem employees) will be in-serviced on their first reported day back to work.
- The DON and or designee will update the Allergy report daily at the clinical meeting (Monday to Friday), and ensure it is available at each nursing station and dining room and a copy will be provided to the kitchen.
- The DON, the Assistant DON (ADON), the MDS Nurse and the DSD observed the licensed nurses checking for tray accuracy prior to trays being served to residents. No issues were identified and the 10 residents who had food allergies and or food intolerances had accurate trays. The DON and ADON assessed the 10 residents for any signs and symptoms of allergic reaction, and none noted.
- The RD provided in-service to final tray line staff who checked Resident 71's breakfast tray.
- The DON reviewed all residents and identified 10 residents with food allergies. Resident 71 the only resident identified to be on a gluten restricted diet. One resident identified having gluten allergy had been hospitalized for unrelated medical condition. Upon this resident readmitted to the facility, the nurse will obtain an order from the MD for allergy test.
- The Regional RD observed breakfast tray line to ensure accuracy of the meal tickets to what was being placed on resident's meal trays. There were no issues identified and the 10 residents who had food allergies and or intolerances had accurate trays.
- The DON completed competency for the licensed nurse who checked Resident 71's tray and met expectations as evidenced by the licensed nurse being able to correctly check the diet orders, resident allergies against the food tray.
- The DON and or designee will complete a random daily visual check of meal trays for residents with identified food allergies using the Daily Food Allergy Audit Form. This audit will remain on-going until the goal is achieved.
- The DON and or designee will review the change in conditions daily related to food allergies.
- The DON and or designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each residents allergies are current, and up to date. This audit will remain ongoing until the goal is achieved.
- The DON obtained an order from Medical Doctor (MD) for Tissue Transglutaminase ([tTG-igA], blood test to diagnose celiac disease, a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food) to be drawn.
- The DON discussed with MD to update Resident 71's gluten intolerance to gluten allergy. The DON updated allergy profile and care plan to reflect resident's gluten allergy. The DON provided dietary communication form to dietary staff for gluten allergy update.
- Registered Nurse Supervisor obtained order from MD for Resident 71 for psychology consult for psychosocial support.
- The RN Supervisor and or designee will update the Allergy report and special needs binder on the weekends (Saturday and Sunday) at each nursing station, and dining room.
- The RD will check food inventory weekly based on the upcoming week's menu using the Inventory form. If any items are missing, the RD will notify the Dietary Manager/designee, and the RD will approve appropriate alternative with same nutritional value if necessary.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, each with significant medical and cognitive needs. For one resident with a history of subdural hemorrhage, atrial fibrillation, and dementia, the call light was observed hanging under the bed and out of reach while the resident was in bed with bilateral siderails up. The resident confirmed she could not reach the call light, and the attending LVN acknowledged the call light was not positioned within reach. Another resident, admitted with hemiplegia, hemiparesis, ataxia, and dysphagia, was found lying in bed with the call light dangling and out of reach. The resident attempted to locate the call light but was unable to find it and stated that she sometimes had to yell for help. A CNA confirmed the call light was not accessible and repositioned it within the resident's reach, stating it should always be accessible. A third resident, with a history of falls, bradycardia, and major depressive disorder, was observed sitting on the bed with the call light on the floor and out of reach. The resident stated that staff had changed his beddings and forgot to return the call light to an accessible position. The ADON confirmed the call light was not within reach and repositioned it. Facility policy and staff interviews confirmed that call lights are required to be accessible to residents at all times.
Failure to Develop Comprehensive Care Plans for Siderail Use and Contact Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically regarding the use of bed siderails and contact isolation precautions. For three residents who used bed siderails, the care plans did not address the use of these devices, despite physician orders and observations confirming their use. Staff interviews and record reviews revealed that the care plans lacked interventions to address the risks associated with siderail use, such as entrapment, and did not provide guidance for staff on prevention or response to such incidents. Facility policy required a bedrail evaluation and care plan reflecting that evaluation, but this was not completed for the affected residents. Additionally, one resident placed on contact isolation due to a multidrug-resistant organism (MDRO) infection did not have a comprehensive care plan addressing the isolation precautions. The resident's care plan did not include person-centered interventions or goals related to managing care needs while on contact isolation. Staff interviews confirmed that the required care plan was not developed, and facility policy mandated that such a plan be created within seven days of the comprehensive assessment. The deficiencies were identified through interviews, record reviews, and direct observations. Staff, including MDS coordinators and nursing leadership, acknowledged the absence of required care plans and interventions for both siderail use and contact isolation. Facility policies and procedures reviewed during the investigation confirmed the expectation for comprehensive, measurable, and timely care plans to address each resident's specific needs, which was not met in these cases.
Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
Licensed nurses at the facility failed to rotate insulin injection sites as required by professional standards and physician orders for three residents with diabetes. For one resident, documentation showed repeated administration of insulin in the same area, such as the left arm or the right lower quadrant of the abdomen, over multiple days. The resident's care plan and physician orders specifically instructed staff to rotate injection sites, but this was not consistently followed, as confirmed by review of the Medication Administration Record (MAR) and interviews with nursing staff. A second resident also received insulin injections in the same location, the left lower quadrant of the abdomen, on consecutive days. The MAR and physician orders indicated the need to rotate injection sites, but this was not done for several days in March. Staff interviews confirmed that the injections were not rotated as required, and the Director of Nursing acknowledged the failure to follow the physician's orders and professional standards. A third resident received both long-acting and sliding scale insulin injections repeatedly in the left upper quadrant of the abdomen over several days, as documented in the MAR. Facility policy and manufacturer guidelines reviewed by surveyors also required rotation of injection sites. Interviews with the Assistant Director of Nursing confirmed that the injection sites were not rotated as required by policy and physician orders.
Failure to Provide Required Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and progression of a pressure ulcer for one resident with an unstageable pressure ulcer. Specifically, the facility did not complete a required weekly measurement and assessment of the resident's wound during one week, as confirmed by both the treatment nurse and the Director of Nursing. The absence of this weekly skin report meant that the licensed nurses and physician did not have updated information on the wound's status, which is essential for monitoring healing or deterioration. Additionally, the facility did not administer the prescribed wound treatment on one day, as evidenced by a blank entry in the Treatment Administration Record. The resident's care plan and physician's orders required daily wound care, including cleansing and application of Thera-Honey gel with a silicone border dressing. The facility's own policy also mandated weekly wound measurements and daily monitoring. These lapses in care were confirmed through interviews and record reviews, indicating a failure to follow both physician orders and facility policy for pressure ulcer management.
Failure to Eliminate Accident Hazards and Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. For one resident with diagnoses including metabolic encephalopathy, dementia, and fluctuating decision-making capacity, a long, looped cable was exposed above the head of the bed and within reach. This resident was observed repeatedly reaching for the cord, which was not secured in the wall-mounted cord protector. Both the Social Services Director and Maintenance Supervisor acknowledged the hazard, noting the resident's confusion and the potential for harm. The resident's care plan specifically called for a clutter-free environment, but this was not maintained. For another resident with muscle weakness, abnormal posture, and a history of lumbar fracture, the facility failed to follow physician orders to place landing pads on both sides of the bed. The resident had previously fallen while reaching for an item and was hospitalized. Despite orders and care plan interventions to reduce fall risk, observations showed that the landing pads were not positioned as required, with one pad against the wall and another in front of an unoccupied bed, both away from the resident. The Assistant Director of Nursing and Director of Nursing confirmed that the pads were not in place as ordered and that staff failed to monitor their placement as required by the physician's order. Both deficiencies were identified through observation, interview, and record review, and were inconsistent with the facility's policies on resident safety and fall management, which require maintaining a safe environment and implementing interventions to reduce fall risk.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that the Antibiotic or Controlled Drug Record accurately matched the quantity of controlled medications present in the medication bubble packs for three residents. During an observation and record review, discrepancies were found between the documented counts on the accountability logs and the actual number of medication doses remaining in the bubble packs for hydrocodone-acetaminophen, pregabalin, and lorazepam. Specifically, one dose each of hydrocodone-acetaminophen and lorazepam was missing for two residents, and both a pregabalin capsule and a hydrocodone-acetaminophen tablet were missing for another resident, with no documentation of administration for these doses. The residents involved had medical histories including chronic pain, osteoarthritis, neuropathy, and anxiety, and were prescribed controlled medications for these conditions. The discrepancies were identified during a medication cart audit, where it was found that the number of doses in the bubble packs did not align with the amounts recorded on the accountability logs after the last documented administration. There was no evidence in the records to account for the missing doses, and the medication administration records did not reflect any additional administrations. A Licensed Vocational Nurse admitted to administering the missing doses to the residents earlier that day but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. The Director of Nursing confirmed that the nurse did not follow the policy of immediate documentation on the accountability records when preparing and administering controlled medications. The facility's policy requires that the administering nurse immediately document the date, time, amount, and signature on the accountability record at the time the medication is removed from the supply.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in two medication errors out of 27 observed opportunities, yielding a 7.41% error rate. The first error involved a resident with chronic kidney disease, anxiety, depression, hypertension, and arthritis, who was prescribed a lidocaine 5% patch to be applied to both wrists for neuropathy. During medication administration, the nurse applied the patch to only one wrist, contrary to the physician's order. The nurse acknowledged not following the five rights of medication administration and recognized this as a medication error. The second error involved a resident with Parkinson's disease, hypotension, and chronic kidney disease, who was prescribed multiple medications, including Omega 3 1000 mg to be administered once daily. During a medication pass, the nurse administered all prescribed medications except for Omega 3. The omission was observed and later confirmed by the nurse, who admitted to failing to follow the five rights of medication administration. The nurse and the DON both recognized this as a medication error and acknowledged that the medication was not administered as ordered. Both incidents were observed and confirmed through interviews with the involved nurses and the Director of Nursing. The facility's policies on medication administration and medication errors require that medications be administered as prescribed and that the medication error rate remain at or below five percent. The observed errors directly contributed to the facility exceeding the acceptable medication error rate.
Failure to Rotate Insulin Injection Sites and Adhere to Medication Hold Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically in the administration of insulin and midodrine. For three residents receiving insulin, staff did not rotate injection sites as ordered by physicians and as required by facility policy. Documentation in the Medication Administration Records (MARs) showed repeated administration of insulin in the same anatomical area over consecutive days, despite clear orders to rotate sites. Interviews with nursing staff and the Director of Nursing confirmed that this practice was not followed, and that such failures were considered medication errors. Additionally, for one resident prescribed midodrine for hypotension, staff did not adhere to the physician's hold parameters. The medication was administered even when the resident's systolic blood pressure exceeded the threshold specified in the order. This was confirmed through MAR review and staff interviews, with the Director of Nursing acknowledging that the medication should not have been given under those circumstances and that this constituted a medication administration error. The residents involved had complex medical histories, including diabetes, end-stage renal disease, major depressive disorder, acute kidney failure, and dementia. All were dependent on staff for various activities of daily living and required careful medication management. The facility's own policies, as well as manufacturer guidelines for insulin, emphasized the importance of rotating injection sites and administering medications according to prescriber orders, but these were not followed in the cited instances.
Failure to Train Dietary Staff on Gluten-Free Diets Leads to Allergen Exposure
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in preparing and serving gluten-free diets, resulting in a resident with a documented gluten allergy being served cream of wheat. The resident, who had diagnoses including cachexia, intestinal malabsorption, and non-celiac gluten sensitivity, was admitted with clear physician orders and allergy documentation indicating the need for a gluten-free and lactose-free diet. Despite these orders, the resident was served cream of wheat, a product containing gluten, for breakfast. The resident identified the error and reported previous instances of being served inappropriate foods, such as oatmeal and regular bread, despite informing staff of his allergies. Interviews with dietary staff revealed confusion and lack of knowledge regarding gluten-free diets. One dietary aide stated she was told by a previous supervisor that cream of wheat was acceptable for gluten-free diets and reported that it was served daily to residents on such diets. The dietary supervisor confirmed that no training on gluten-free diets had been provided to kitchen staff since assuming her position. Additionally, the registered dietitian acknowledged that the facility's menu software did not properly flag the resident's gluten allergy, and there was a lack of clarity regarding the availability of gluten-free alternatives such as cream of rice, which was in stock but not used. A review of facility policies, procedures, and competency checklists showed that while staff were trained on general food allergies and preferences, there was no specific training or competency verification for gluten-free diets. The facility's policies required identification and accommodation of food allergies, but these were not effectively implemented. The deficiency was further evidenced by the lack of accurate tray identification and the absence of gluten-free diet training in staff in-service records.
Failure to Verify Meal Tray Contents Against Updated Allergy Information
Penalty
Summary
The facility failed to ensure that kitchen staff or licensed nurses checked the contents of a meal tray against the meal tray ticket for a resident during breakfast service. Specifically, a resident with a history of paraplegia and moderate cognitive impairment was served apple juice, despite the meal tray ticket indicating an allergy to apple juice. The resident confirmed they were not allergic to apple juice, and previous assessments and care plan updates had removed apple juice from the resident's allergy list. However, the meal tray ticket still listed the allergy due to a system glitch during a transition to a new dietary meal ticket system. Dietary staff did not review the tray on the day in question, and the discrepancy between the resident's actual allergy status and the information on the meal tray ticket was not identified by either dietary or nursing staff. The facility's policy required both dietary and nursing staff to check trays for correct diets and allergies before serving, but this process was not followed, resulting in the resident being served an item incorrectly listed as an allergen on their tray ticket.
Deficient Food Preparation and Service Affecting Palatability and Safety
Penalty
Summary
Surveyors identified that the facility failed to ensure food was prepared and served in a manner that conserved temperature, flavor, and appearance. Specifically, pineapple Bavarian cream and its pureed version were served at 70°F and 73°F, respectively, which was above the required cold holding temperature of 41°F or below. The Dietary Supervisor confirmed these temperatures were not acceptable for palatability and could result in residents not eating the food. Facility policies and standardized recipes required cold desserts to be maintained at or below 41°F during service, but this was not followed. Additionally, cheese enchiladas served to residents were observed to be dry, hard, and lacking sufficient sauce, making them crunchy rather than soft as intended. Both the Dietary Supervisor and Registered Dietitian agreed that the enchiladas did not meet the expected quality, with the Registered Dietitian noting that the food was not palatable and could lead to dissatisfaction. The standardized recipe for cheese enchiladas specified that each portion should be topped with sauce, which was not adhered to during meal service. Pureed mixed vegetables were also found to be runny, with liquid separating from the puree, rather than holding their shape as required by the facility's recipe and texture standards. The Registered Dietitian and Dietary Supervisor both noted that the puree did not meet consistency requirements, as it failed the spoon tilt and fork drip tests outlined in the recipe. These deficiencies in food preparation and service placed a significant number of residents at risk of poor food intake and related complications.
Failure to Provide Properly Prepared Pureed Foods for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents on a puree diet. Observations revealed that the puree cheese enchilada was grainy, the puree rice contained rice grains, and the puree vegetables had a runny consistency with liquid separating from the product. These issues were identified during meal preparation and trayline assembly, where it was noted that the foods did not meet the required smooth, pudding-like consistency for pureed diets. During a test tray evaluation, both the Dietary Supervisor (DS) and Registered Dietitian (RD) confirmed that the puree cheese enchilada was not smooth enough, the puree rice still had chunks, and the puree vegetables were excessively runny with liquid separation. The RD stated that the puree foods should be smooth, lump-free, and hold their shape, as outlined in the facility's diet manual and standardized recipes. The DS also noted that the runny puree vegetables would likely be unappealing to residents and could result in decreased food intake. A review of the facility's policies and procedures, diet manual, and standardized recipes indicated that all pureed foods should meet the International Dysphagia Diet Standardisation Initiative (IDDSI) Level 4 guidelines, which require foods to be lump-free, not sticky, and able to hold their shape without liquid separation. The facility's failure to adhere to these guidelines during food preparation and service resulted in the provision of pureed foods that did not meet the prescribed consistency and texture for residents requiring modified diets.
Deficient Food Storage, Sanitation, and Labeling Practices Identified
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Observations revealed that multiple racks in both the walk-in refrigerator and dry storage room were corroded with amber discoloration, and all resident meal trays were cracked and chipped. Both the Registered Dietitian and Dietary Supervisor confirmed that these surfaces were not smooth, were difficult to clean, and needed replacement to prevent bacterial contamination. Facility policies and the Food Code require food-contact surfaces to be smooth and free of cracks or rust, but these standards were not met. Further observations showed that kitchen equipment and areas were not properly cleaned and sanitized. The walk-in refrigerator and freezer floors had visible food debris, including pieces of bread, cream cheese, and sandwich spread, as well as dirt. The chest freezer had dust buildup and a sticky door, and the walk-in refrigerator gasket was dirty. Staff interviews confirmed that these areas were supposed to be cleaned regularly, but the cleaning schedule was not sufficient to maintain sanitation. Facility policies and the Food Code require regular cleaning of both food-contact and non-food-contact surfaces to prevent accumulation of soil and contamination. Additionally, dietary staff were observed wearing bracelets made of gold, leather, and rubber during food preparation and pot washing, in violation of both facility policy and the Food Code, which prohibit jewelry other than a plain wedding band during food handling. In a separate incident, a resident's leftover food brought from outside was not labeled with the resident's identifier or use-by date, contrary to facility policy. The Director of Staff Development confirmed that such labeling is required to prevent foodborne illness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed improper disposal of garbage and refuse in the facility, including 15 soiled gloves, an empty spray bottle, plastic, and other trash scattered on the ground near the dumpster area. One of three dumpsters was found to have brown dried food spills and dirt on its surface. During interviews, both the Dietary Supervisor and the Environmental Services Supervisor acknowledged the presence of soiled gloves and trash on the floor, as well as the unclean condition of the dumpster, and stated that these conditions were not acceptable. The facility's policy and procedure required that outside dumpsters be kept closed and free of surrounding litter, and the Food Code 2022 specified that garbage and refuse must be properly stored and disposed of to prevent attracting pests and spreading infection. The observed failures had the potential to attract birds, flies, insects, and pests, possibly spreading infection to 142 of 149 residents. The Environmental Services Supervisor stated that the area was expected to be cleaned daily and dumpsters washed weekly, but these standards were not met at the time of the survey.
Infection Control Deficiencies: Unlabeled Urinals and Contaminated Oxygen Tubing
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. For one resident, the nasal cannula oxygen tubing was observed lying on the floor during a concurrent observation and interview with the Infection Preventionist (IP). The IP confirmed that the tubing was contaminated and needed immediate replacement, as it could introduce bacteria to the resident. The resident had diagnoses including cachexia and atelectasis, required partial to moderate assistance with activities of daily living, and had an order for oxygen therapy via nasal cannula as needed for low oxygen. Additionally, the facility did not ensure that urinals used by two residents were labeled with resident identifiers. In one case, a plastic urinal bottle at a resident's bedside was found without any written identifier, and the IP stated that labeling was necessary to prevent accidental use by roommates. In another case, two unlabeled urinals were observed at a different resident's bedside, and a Certified Nursing Assistant (CNA) confirmed the lack of labeling. The IP emphasized the importance of labeling urinals to prevent cross-contamination among residents. The facility's policy on Standard Precautions requires that all resident-care equipment soiled with blood, body fluids, secretions, and excretions be handled in a manner that prevents contamination and transfer of microorganisms. However, the Director of Nursing (DON) stated that there was no specific policy addressing the labeling of urinals for infection control. The observations and interviews confirmed that the facility did not consistently implement its own infection control policies regarding the handling and labeling of resident care equipment.
Failure to Return Deceased Resident's Personal Belonging
Penalty
Summary
The facility failed to ensure that a resident's personal belonging, specifically a silver bracelet, was returned to the resident's representative following the resident's death. Upon admission, the resident, who was receiving palliative care for end stage renal disease, had a silver bracelet documented on the Inventory of Personal Effects (IPE) form. After the resident expired in the facility, there was no documentation indicating that the bracelet was turned over to the facility, and staff were unable to locate the item. During an interview and record review, the Social Services Director confirmed that all personal belongings are to be inventoried and released to the family upon a resident's discharge or death, as per facility policy. The Director acknowledged that the silver bracelet was not accounted for and had not been returned to the resident's representative. The facility's policy requires safeguarding and proper release of personal belongings, but in this instance, the process was not followed, resulting in the loss of the resident's possession.
Failure to Inform Resident of Medication Names and Indications During Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered multiple medications to a resident without informing them of the names and indications of each medication prior to administration. The resident, who had a history of chronic kidney disease, anxiety, depression, hypertension, and arthritis, and was assessed as having moderate cognitive impairment, received several oral medications and a lidocaine patch during a morning medication pass. The LVN did not provide the resident with information about the medications or their purposes at the time of administration. During interviews, the LVN acknowledged failing to inform the resident of the medication names and indications, stating that this step is usually performed but was forgotten on this occasion. The Director of Nursing confirmed that the LVN did not follow facility policy, which requires informing residents about their medications and their purposes to support resident rights. Review of facility policy indicated that residents have the right to be informed of and participate in their care planning and treatment.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or the resident's representative in the quarterly Interdisciplinary Team (IDT) Care Conference for the development of an individualized Comprehensive Care Plan. The resident, who had diagnoses including gastroesophageal reflux disease and hypertension, was cognitively intact and required staff assistance with activities of daily living. Despite this, the resident was not included in discussions regarding discharge plans or care goals, and was unaware of his discharge status or plans, expressing frustration about not being consulted. Record review and staff interviews confirmed that the IDT Care Conference notes did not document participation by the resident or the resident's representative, contrary to facility policy which requires such involvement to the extent possible. The facility's policies also specify that care plans should be individualized and developed collaboratively with the resident or their representative. The lack of resident involvement led to the resident's frustration and the potential for unmet physical and psychosocial needs.
Failure to Update Care Plans After Resident Fall and Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to review and update care plans for two residents following significant changes in their conditions. For one resident with a history of muscle weakness, abnormal posture, and a lumbar fracture, the care plan for fall risk was not revised after the resident experienced a fall while attempting to reach for a document, which resulted in hospitalization due to low oxygen saturation. Although new physician orders were issued to place the bed in a low position with bilateral landing pads and to monitor their placement, these interventions were not incorporated into the resident's care plan. Both the MDS Coordinator and the Director of Nursing confirmed that the care plan was not reviewed or updated after the fall, despite facility policy requiring such updates following a change in condition or hospital readmission. Another resident with chronic obstructive pulmonary disease, major depressive disorder, and respiratory failure had a care plan that was not updated after the discontinuation of continuous oxygen therapy. The resident's care plan continued to list oxygen administration as an intervention even after the physician order for oxygen was discontinued following a hospitalization. Observations revealed that the resident was still using oxygen equipment in the room, and staff were unaware that the order had been discontinued. The Director of Nursing confirmed that the care plan had not been revised to reflect the change in physician orders, and the resident was not informed that oxygen was no longer required. Facility policies reviewed indicated that care plans should be updated to reflect new interventions after a fall or a significant change in a resident's condition, including changes in physician orders. The failure to update care plans in both cases was acknowledged by facility staff and was not in accordance with the facility's own policies and procedures.
Failure to Provide Necessary ADL Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including abnormal posture, weakness, dysphagia, and unspecified dementia was admitted to the facility and was documented as being dependent on staff for activities of daily living (ADLs) such as toileting, dressing, and personal hygiene. The resident's care plan included interventions for dressing and changing as needed. However, observations and interviews revealed that the resident's clothing had not been changed for three days, as evidenced by a persistent red food stain on the left sleeve of the resident's long-sleeved shirt. Family and staff confirmed the clothing had not been changed, and the stain appeared old and dried. Additionally, it was observed and reported that the resident's teeth were not brushed after breakfast, leaving brownish dried residue on the teeth. Staff interviews confirmed that residents should have their clothing changed and teeth brushed at least once daily. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming, dressing, and personal and oral hygiene, as well as the right to a dignified existence. These services were not provided as required for this resident.
Failure to Provide and Document Indwelling Catheter Care
Penalty
Summary
A deficiency was identified when a resident with an indwelling catheter did not receive proper catheter care as outlined in their care plan. The resident, who had diagnoses including dysphagia, major depressive disorder, and type 2 diabetes mellitus, was dependent on staff for personal hygiene and bathing. The care plan required daily and as-needed catheter care, monitoring for signs and symptoms of infection, and skin irritation checks every shift. However, review of the Treatment Administration Record (TAR) showed no evidence that licensed staff provided or documented daily catheter care, infection monitoring, or skin assessments as required. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the required catheter care and monitoring were not documented or performed according to the resident's care plan. The facility's policy on urinary catheters emphasized the importance of such care to prevent complications, but staff failed to implement and record these interventions for the resident.
Failure to Obtain Physician Orders and Label Oxygen Tubing for Respiratory Care
Penalty
Summary
The facility failed to implement its own policy and procedure for oxygen administration by not obtaining a physician's order prior to administering oxygen to two residents. In the case of one resident with a history of COPD, major depressive disorder, and respiratory failure, the resident had previously received continuous oxygen therapy as ordered by a physician. However, after the physician's order for oxygen was discontinued following a hospitalization, staff continued to provide oxygen without a current physician's order. This was confirmed through interviews and record reviews, where both the LVN and DON acknowledged the absence of a valid order and the ongoing administration of oxygen. For another resident with a history of amputation, osteomyelitis, diabetes, asthma, and sleep apnea, oxygen was administered for shortness of breath without a physician's order. The resident's care plan indicated a risk for respiratory complications and included interventions for oxygen therapy as ordered, but no current physician order was found in the records. Staff confirmed that oxygen had been given and that the tubing and nasal cannula used for oxygen delivery were not labeled with the date they were last changed, as required by facility policy. Observations revealed that the oxygen tubing for this resident remained in the room and was not labeled, and staff interviews confirmed that the tubing had not been changed or labeled according to protocol. The facility's policy required verification of a physician's order before oxygen administration and mandated that oxygen tubing be labeled with the date of the last change to prevent infection. These requirements were not followed in both cases, as confirmed by staff and record review.
Improper Labeling and Storage of Inhalation Medication
Penalty
Summary
Surveyors observed that an opened budesonide inhalation solution foil pouch for one resident was not labeled with the date it was opened, and five inhalation solution ampules were stored outside the protective foil pouch in a medication cart. The Licensed Vocational Nurse (LVN) confirmed that the facility's policy requires multi-dose products, such as inhalation solutions, to be labeled with the date they are first opened to determine their expiration. The LVN also stated that, according to the manufacturer's guidelines, inhalation solutions must remain in the foil pouch or, if stored outside, be discarded within two weeks. Since the date of opening was not documented, it was unknown when the five ampules would expire, and they were considered expired and potentially ineffective. The Director of Nursing (DON) confirmed that inhalation solutions removed from their foil pouches must be labeled with the date of removal to determine the beyond use date, and that any solutions stored outside the pouch expire in two weeks. The facility's policy and the manufacturer's instructions both require proper labeling and storage to ensure medication effectiveness. The failure to label and store the budesonide inhalation solutions as required resulted in the presence of potentially expired medication in the medication cart, with no way to determine if it was still safe or effective for use.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely reporting of an allegation of misappropriation of resident property. Specifically, after a resident reported missing money following a hospital stay, the facility did not notify the State Survey Agency, the ombudsman, or local law enforcement within 24 hours as required. The resident, who had diagnoses including acute kidney failure, diabetes type 2, and atherosclerotic heart disease, reported the missing money to the administrator and was assured it would be returned, but did not receive it. The theft/loss report was initiated, and an internal investigation was conducted, including staff interviews and searches, but no money was found and the police were not notified. The administrator confirmed that the allegation was investigated and found to be unsubstantiated, but acknowledged that the required notifications to authorities were not made. The facility's policy clearly states that such incidents must be reported to specific agencies and individuals within 24 hours, and the results of the investigation must be reported within five working days. The failure to report the allegation as required constituted a deficiency in the facility's handling of suspected misappropriation of resident property.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Money
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of money reported by a resident with intact cognition and multiple medical conditions, including acute kidney failure, diabetes type 2, and atherosclerotic heart disease. After returning from a hospital stay, the resident reported missing money, initially estimated between $20 and $50, but later stated the amount was $400. The resident kept his money in his bedside table and did not take his wallet during the hospitalization. The theft/loss report was initiated, and staff interviews and searches were conducted, but the police were not notified, and the investigation did not include all relevant staff. Documentation revealed inconsistencies regarding the amount of money the resident possessed, with inventory records indicating no money, while a staff member later observed a wallet with about $30 in the resident's bedside table. This staff member did not secure the wallet with social services until the resident's return. The Director of Social Services confirmed there was no follow-up with the resident after the report, and the resident continued to keep money in his wallet at the bedside despite being offered the facility safe. The Director of Nursing acknowledged that staff should have secured valuables and that all staff involved should have been interviewed to ensure a thorough investigation. The Administrator confirmed the allegation was not reported to the state agency, ombudsman, or law enforcement, and was unaware of the staff member's observation of the wallet until after the fact. The facility's policy required prompt investigation of all theft or misappropriation reports, but this was not fully carried out in this case.
Incorrect Discharge Location Coded on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge location on the Discharge Minimum Data Set (MDS) for one resident who had been discharged. The resident, who had Alzheimer's Disease and was severely cognitively impaired, was admitted to the facility and later discharged. Documentation in the Admission Record, Physician's Orders, Discharge Summary, and Discharge Plan all indicated that the resident was discharged to an assisted living facility, which is a lower level of care. However, the MDS assessment incorrectly coded the discharge location as a short-term general hospital. During an interview and record review, the MDS Coordinator acknowledged the error, stating that the discharge section of the MDS was completed incorrectly and that the resident was actually discharged to an assisted living facility. The facility's policy requires that all portions of the MDS assessment be completed accurately and certified by the responsible staff. The inaccurate coding on the MDS resulted in an inaccurate assessment for the resident.
Incomplete Medication Reconciliation and Education at Discharge
Penalty
Summary
The facility failed to ensure a complete reconciliation of medications was provided upon discharge for three residents. For Resident 1, the discharge plan documentation indicated a reference to a medication list, but the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse 2 (LVN 2) confirmed that the medication list was incomplete, lacking details on the medications and quantities provided to the resident upon discharge. Similarly, for Resident 3, the discharge plan documentation referenced an attached medication list, but neither LVN 3 nor Registered Nurse 1 (RN 1) could confirm the medications or quantities provided, as the documentation was incomplete. Resident 4's discharge documentation also failed to include a medication list, as confirmed by RN 1 and the Director of Nursing (DON). Additionally, the facility did not provide adequate information regarding the monitoring of potential side effects for Resident 1, who was discharged with prescriptions for apixaban and Plavix, both of which require monitoring for signs of bleeding. LVN 2 and RN 1 confirmed that there was no documentation or communication to Resident 1 or their family about monitoring for bleeding, a critical aspect of the resident's post-discharge care. The DON also confirmed the absence of documentation regarding this necessary education. The facility's policy and procedure for preparing a resident for discharge, which includes preparing a discharge summary and post-discharge plan, was not followed. The policy requires that medications to be discharged with the resident are prepared and that the resident or their representative is provided with the necessary documents, including a discharge summary and plan. The failure to adhere to these procedures resulted in incomplete discharge documentation and inadequate communication of critical post-discharge care instructions.
Failure to Use PPE for Resident on Contact Isolation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Attendant (CNA) was wearing personal protective equipment (PPE) while in the room of a resident who was on contact isolation precautions. The resident, who had been admitted and readmitted to the facility with diagnoses including left knee replacement surgery, osteoarthritis, acute respiratory failure, and dementia, was under contact isolation due to a positive test for Clostridium difficile (C-diff), a germ that causes diarrhea. The CNA was observed in the resident's room without PPE, despite signage indicating the need for PPE and the presence of an isolation cart with gowns, gloves, and masks. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the resident was under contact isolation and that PPE should have been worn by anyone entering the room. The facility's policy on Clostridium Difficile and Isolation-Categories of Transmission-Based Precautions outlined the need for contact precautions, including wearing a disposable gown upon entering the room and removing it before leaving. The CNA acknowledged the failure to wear PPE, which was a breach of the facility's infection prevention and control protocols.
Failure to Provide Tissues for Resident Hygiene
Penalty
Summary
The facility failed to ensure that tissue boxes were readily available for two residents, which hindered their ability to maintain personal hygiene independently. Resident 3, who was admitted with chronic kidney disease, was observed without a tissue box in their room. Despite being able to understand and communicate needs, Resident 3 expressed a desire for tissues to be within reach to clean their face and hands without needing to call staff. The care plan for Resident 3 emphasized encouraging independence by placing frequently used items within reach, yet this was not adhered to. Similarly, Resident 1, admitted with cardiomegaly, also did not have a tissue box available at the bedside. Resident 1 required moderate to maximum assistance with personal hygiene and had requested a new tissue box, which was not provided. The facility's policy indicated that tissues should be supplied as part of routine personal hygiene items without extra charges. Observations and interviews with staff confirmed the absence of tissue boxes for both residents, despite the facility's admission agreement and policy stating that such items should be automatically replenished to meet residents' basic needs.
Failure to Document Resident Grievance
Penalty
Summary
The facility failed to document and file a grievance made by a resident, which was not recorded in the facility's grievance log. The resident, who was cognitively intact and capable of making decisions, had complained about her roommate and the roommate's son being loud during late-night visits, which disturbed her rest. Despite being aware of the grievance during a staff meeting, the Social Services Designee did not document it due to time constraints. The facility's policy requires grievances to be documented on a grievance form and logged in the grievance log to ensure timely resolution. However, this procedure was not followed, as confirmed by the Social Services Director, who emphasized the importance of logging grievances for tracking and resolution purposes. The facility's policy mandates that grievances be resolved within 72 hours, but the failure to document this grievance meant it was not addressed according to the established protocol.
Failure to Develop Care Plan for Financial Abuse Allegation
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who made an allegation of financial abuse. The resident, admitted with multiple diagnoses including metabolic encephalopathy, dementia, rhabdomyolysis, cachexia, and a history of falling, had severely impaired cognition as indicated in their Minimum Data Set (MDS). Despite a documented change in condition when police officers arrived at the facility due to the financial abuse allegation, no specific care plan addressing this issue was created. Interviews with facility staff revealed that the Registered Nurse Supervisor and the Minimum Data Set Nurse acknowledged the absence of a care plan specific to the financial abuse allegation. The facility's policy requires an individualized comprehensive care plan with measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case. The lack of a specific care plan for the financial abuse allegation was identified as a deficiency, potentially affecting the delivery of care and services to the resident.
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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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