Woods Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in La Verne, California.
- Location
- 2600 A Street, La Verne, California 91750
- CMS Provider Number
- 056083
- Inspections on file
- 45
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Woods Health Services during CMS and state inspections, most recent first.
A resident with dementia, muscle wasting, and type 2 DM, assessed as severely cognitively impaired and needing substantial/maximal assistance with ADLs, had a care plan identifying high fall risk due to confusion and balance problems and requiring a 2-person assist for all transfers using an EZ stand. Despite this, a CNA and the resident’s responsible party reported that the CNA used the EZ stand alone to transfer the resident to the bathroom, contrary to the documented intervention. The DON confirmed that care plans are intended to direct staff interventions and that fall-risk interventions are to be followed, and facility policy required comprehensive person-centered care plans to be developed and implemented for each resident.
The facility did not complete required annual performance evaluations for multiple CNAs, as shown by personnel records indicating that several CNAs had no documented reviews for one or more years despite a written policy requiring annual evaluations by supervisors. The DSD confirmed that no CNA performance reviews had been conducted since she assumed her role, even though she acknowledged they should occur yearly. This deficiency was identified through staff interviews and review of employment records and facility policy.
A resident with a history of atrial fibrillation and hypertension was admitted with a critically low BP, but staff did not notify the physician as required by facility policy. The resident later experienced a fall, and interviews confirmed that staff recognized the need to report such findings but failed to do so, with no documentation of physician notification in the records.
A resident with a history of atrial fibrillation, hypertension, and recent low blood pressure was admitted with clear indicators of high fall risk, including a fall risk bracelet and a high Fall Risk Evaluation score. Despite these factors, staff did not notify the physician of the resident's hypotension or implement additional fall prevention interventions. The resident subsequently slid off the bed while attempting to use a urinal, with persistently low blood pressure documented before and after the fall. Staff interviews confirmed that required notifications and interventions were not completed.
A resident with a left first toe fracture did not receive treatment as ordered by the physician and orthopedic specialist, as staff failed to document or implement buddy taping or splinting of the toe. Nursing staff did not transcribe the orthopedic recommendations into orders, and there was no record of the treatment being provided, contrary to facility policy.
A resident with a surgical wound was admitted without a complete wound assessment or timely treatment order, and wound care was not consistently provided as prescribed. The wound was left uncovered and dressing changes were missed, resulting in the development of an infection that required hospital transfer and treatment.
A resident admitted with a surgical wound on the left hip did not have the wound documented or described by the admitting RN, and subsequent LTC evaluations by staff also failed to include required wound descriptions and measurements. This resulted in incomplete and inaccurate medical records, contrary to facility policy requiring objective, complete, and accurate documentation.
A resident admitted with a healing surgical wound and multiple complex diagnoses did not have a treatment order for the wound included in their care plan until nearly two months after admission. Nursing staff confirmed the omission, and review showed the care plan failed to address the required wound care intervention as outlined in facility policy.
A resident with severe cognitive impairment was administered Seroquel, a psychotropic medication, for psychosis without documented informed consent from the responsible party. Facility staff and policy confirmed that consent was required prior to administration, but records showed the medication was given without this step, leaving the responsible party uninformed about the risks and benefits.
A resident with severe cognitive impairment and multiple diagnoses did not have medication irregularities identified by the pharmacist communicated to their physician. Recommendations regarding GI medications, a statin, and an antipsychotic dose reduction were not acted upon, and there was no documentation of physician review or response, contrary to facility policy.
Staff did not follow Enhanced Barrier Precautions by failing to wear PPE while providing care to a resident on isolation, and two residents' nasal cannula tubing was observed touching the floor, contrary to infection control protocols. Facility staff and leadership acknowledged these lapses, which were not in line with established policies for infection prevention.
A resident with severe visual impairment was unable to access the call light, which was left out of reach, and another resident with multiple medical conditions experienced a significant delay in having their call light answered for needed treatment. Staff and policy confirmed that call lights should be accessible and answered promptly, but these expectations were not met in both cases.
A resident with a history of stroke and other medical conditions was prescribed Plavix, an antiplatelet medication, but the MDS was incorrectly coded to indicate anticoagulant use. The MDS Nurse and DON confirmed that antiplatelet and anticoagulant medications should be coded separately, and the error was identified during record review and staff interviews.
A resident with heart failure and other conditions was admitted with an active hospice order, and both the care plan and staff interviews confirmed ongoing hospice care. However, the MDS assessment did not reflect the resident's hospice status, resulting in inaccurate documentation.
A resident with multiple medical conditions and cognitive impairment was given several medications by an LVN without being informed about the medications, their purposes, or potential side effects. Interviews with the LVN, the resident, and the DON confirmed that the resident was not provided with this information, despite facility policies supporting residents' rights to be informed and involved in their care.
A resident with multiple medical conditions, including heart failure and asthma, was observed receiving a higher oxygen flow rate than ordered via nasal cannula. Although records indicated compliance with the physician's order for three liters per minute, direct observation revealed the resident was receiving four liters, and staff confirmed the error and corrected it. Facility policy and staff interviews emphasized the requirement to follow physician orders for oxygen administration.
A resident with severe cognitive impairment, a history of falls, and dependence for mobility was found with only one floor mat beside the bed, despite a physician order and care plan requiring mats on both sides. Staff interviews and record reviews confirmed the order was not followed, resulting in noncompliance with prescribed safety interventions.
The facility did not post actual nursing hours for all shifts and failed to display nurse staffing information in a location accessible to residents and visitors. Staffing sheets were only available at the nursing station and did not include required details such as total and actual hours worked per shift for licensed and unlicensed staff, as confirmed by interviews with the SA and DON.
Surveyors found that expired food was stored in a kitchen refrigerator and that required sanitation and equipment cleaning logs, including those for sanitizer concentration, ice machine cleaning, and dish machine temperature, were incomplete and missing required managerial review. The dietary supervisor confirmed these lapses and referenced facility policies requiring proper food storage and daily log completion.
A resident's discharge destination was inconsistently documented, with the MDS indicating discharge to a hospital while the Discharge Instruction Form showed discharge to a LTC center. The MDS Coordinator acknowledged the error, and the DON emphasized the importance of accurate records for care planning and post-discharge support.
The facility failed to monitor healthcare personnel for RSV symptoms after exposure to two residents who tested positive. Despite placing the residents in isolation, the Infection Prevention Nurse did not track staff or resident contacts, and the Director of Nursing confirmed no such tracking occurred. The facility's infection control policy lacked procedures for tracking exposures, contrary to CDC guidelines, potentially allowing RSV to spread.
A CNA failed to perform hand hygiene during meal service, moving between two residents without washing hands, which could lead to cross-contamination. One resident had a femur fracture and gastrointestinal issues, while the other had a history of myocardial infarction and UTIs. The facility's policy required handwashing before and after resident care, which was not followed.
A facility failed to accurately complete the infection monitoring form during an influenza outbreak for a resident. The resident was admitted with influenza, pneumonia, and respiratory failure, but the forms inaccurately indicated symptoms before admission. The DON acknowledged the error, noting the importance of accurate documentation for patient care and compliance.
The facility failed to revise care plans and implement new interventions for two residents after multiple falls, despite having policies in place for falls management and care plan revisions. Both residents had documented falls, but their care plans were not updated, as confirmed by staff interviews. This deficiency placed the residents at risk for further falls and injuries.
A facility failed to document the cancellation of a urology consult for a resident with congestive heart failure, bradycardia, and Parkinson's disease. Staff interviews confirmed the cancellation was known but not recorded, violating the facility's documentation policy and leading to communication gaps among staff.
A resident tested positive for Hepatitis A, but the facility failed to report the case to the California Department of Public Health (CDPH), only notifying the County of Los Angeles Department of Public Health. The Director of Nursing was unaware of the requirement to report to CDPH, despite facility policies mandating such reporting for communicable diseases.
A facility failed to adhere to infection control practices when a housekeeper entered a Covid-19 isolation room without required eye protection, and staff left personal tumbler cups in a designated Covid-19 area. The housekeeper did not wear goggles or a face shield as required, and the Infection Preventionist Nurse noted the risk of cross-contamination from the cups, which were improperly stored in the red zone.
The facility failed to answer call lights in a timely manner for seven residents, leading to frustration and potential psychosocial decline. Residents reported waiting up to an hour for assistance, causing frustration and self-reliance for bathroom needs. Staffing shortages and increased resident assignments contributed to the delays, as acknowledged by the DON.
The facility failed to develop comprehensive care plans for three residents, including one with dementia and psychosis, another with diabetes and dysphagia, and a third with severe cognitive impairment. The care plans lacked specific interventions, measurable objectives, and timeframes, leading to potential gaps in care.
The facility failed to follow physician's orders for a resident's antihypertensive medications, administering Losartan and Metoprolol despite blood pressure readings below the specified parameters. This non-compliance with medication administration protocols had the potential to adversely affect the resident's health.
The facility failed to provide sufficient staffing, resulting in delayed toileting and incontinence care for seven residents. Residents reported waiting times ranging from 10 minutes to over an hour for assistance, leading to discomfort and potential health risks. Staff interviews confirmed that call-offs and increased resident assignments contributed to the delays. The facility's policies indicated that call lights should be answered within 3-5 minutes, but the observed delays indicated a failure to meet these standards.
The facility failed to follow proper food storage and preparation practices, with unlabeled and undated food items and cold foods not maintained at the required temperature. This had the potential to cause foodborne illness and affect food quality for residents.
The facility failed to follow standard infection control practices by not safely storing personal toiletries for two residents and lacked a surveillance plan to monitor infections other than COVID-19. Personal items were found unlabeled and improperly stored, and the facility did not track infections, relying instead on the public health nurse for advice.
A facility failed to ensure a resident's call light was within reach, as required by the resident's care plans and facility policy. The resident, who had multiple diagnoses including Alzheimer's disease, was observed unable to reach the call light, which was later corrected by a CNA. Staff interviews confirmed the importance of call light accessibility for resident safety.
The facility failed to ensure that a resident had directions or instructions regarding treatment requests and wishes in the event of a medical emergency. Despite having an intact cognitive status, the resident did not have a completed POLST form or an advance directive. Staff acknowledged the importance of these documents, but the facility did not discuss the resident's treatment wishes, leading to the potential for inappropriate or unnecessary care.
The facility failed to ensure accurate completion of a resident's MDS, incorrectly documenting that the resident was receiving oxygen therapy and tracheostomy care. Both the MDS Assistant and the DON confirmed the inaccuracy, which could lead to inappropriate care based on incorrect information.
The facility failed to maintain a high-risk resident's bed in a low position, despite multiple falls and clear care plan instructions. The resident, with severe cognitive impairment and a history of falls, was observed with their bed elevated, contrary to documented preventive measures.
A facility failed to follow the physician's order to check a resident's colostomy site every shift and change the leaky colostomy bag in a timely manner. The resident reported a lack of necessary supplies for three weeks, and an observation confirmed the colostomy flange was not secured and soiled. The RN and DON acknowledged the need for timely changes, but the supplies were still en route.
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. The resident, with diagnoses including heart failure and dementia, was observed receiving 4 1/2 liters of oxygen instead of the prescribed 3 liters. This discrepancy was confirmed by both the resident's Responsible Party and a Registered Nurse, indicating a lapse in adherence to professional standards and physician orders.
A resident had an order for Lorazepam without an end date within 14 days, against regulations. Despite a recommendation to discontinue the order, it remained active due to the family's wishes. The resident's Medication Administration Record showed no administration of Lorazepam during the review period, but the order was not properly re-evaluated.
The facility's Infection Preventionist (IP) had not completed the required specialized training, being only on module five of 24. The Director of Nursing (DON) confirmed that the IP was still in training and was assisting with IP duties. The facility's job description required the IP to complete specialized training, which had not been met.
A resident with a history of falls sustained a hip fracture after the facility failed to implement physician-ordered safety measures, including bilateral floor mats and a silent bed/chair alarm. Despite documented high fall risk and necessary interventions, these measures were not in place, leading to the resident's fall and injury.
Failure to Follow Care Plan Requiring Two-Person Assist With EZ Stand Transfer
Penalty
Summary
Surveyors identified a deficiency in the implementation of a comprehensive person-centered care plan when staff did not follow the documented transfer assistance requirements for a resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and dementia, and an MDS assessment showed the resident was severely impaired in cognitive skills and required substantial/maximal assistance for bathing, dressing, toileting hygiene, oral hygiene, and personal hygiene. The resident’s care plan, developed and later revised due to high fall risk related to confusion and balance problems, specified the intervention to use a 2-person assist for all transfers with an EZ stand. Despite this care plan intervention, a CNA reported, and the resident’s responsible party confirmed, that on a specified evening the CNA used the EZ stand alone to transfer the resident to the bathroom, without a second staff member assisting. The DON acknowledged that the purpose of the care plan was to communicate interventions staff should use to address resident needs and that interventions related to fall risk should be followed by staff. The facility’s policy on comprehensive person-centered care plans stated that a care plan with measurable objectives and timetables must be developed and implemented for each resident, but in this instance the intervention requiring two staff for EZ stand transfers was not implemented as written.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for four sampled CNAs, contrary to its policy and the Director of Staff Development’s (DSD) stated expectations. Review of CNA 1’s employment record showed hire on 4/25/2024 and a last performance review on 11/4/2024, with no review documented for 2025. CNA 2’s record showed a last performance review on 12/30/2024, with no review documented for 2025. CNA 4, hired on 7/19/2007, had a last performance review dated 12/28/2023, with no reviews documented for 2024 or 2025. CNA 5, hired on 10/16/2023, had a last performance review on 2/12/2024, with no review documented for 2025. In an interview on 2/10/2026, the DSD stated that performance reviews should be done annually and acknowledged that she had not completed any performance reviews for CNAs since starting in April 2025. Review of the facility’s September 2020 policy titled “Job Descriptions and Performance Evaluations” confirmed that annual performance reviews are required to be completed by the employee’s direct supervisor. This failure had the potential to result in CNAs providing improper care, making clinical errors, and causing resident injury, as identified by the surveyors based on the interview and record review.
Failure to Notify Physician of Resident's Critically Low Blood Pressure on Admission
Penalty
Summary
Facility staff failed to notify a resident's physician of a significantly low blood pressure (BP) reading upon admission. The resident, who had a history of atrial fibrillation and hypertension, was admitted with an initial BP of 64/40 mm/Hg. Despite this abnormal finding, there was no documentation or evidence that the physician was informed of the low BP, as confirmed by interviews with nursing staff and review of progress notes. The facility's policy required that hypotension, defined as BP less than 100/60 mm/Hg, be reported to the physician. On the evening of admission, the resident was found on the floor after slipping off the bed while attempting to use a urinal. At the time of the fall, the resident's BP remained low at 65/41 mm/Hg. Subsequent BP readings taken every 15 minutes showed gradual improvement, but the initial hypotensive episode was not communicated to the physician. Interviews with staff indicated awareness that such low BP readings should be reported, but the responsible nurse did not do so, citing being overwhelmed by multiple admissions. The Director of Nursing confirmed that there was no documented communication with the physician regarding the resident's low BP and acknowledged that staff should have monitored and reported the abnormal vital sign. The lack of physician notification was not documented in the resident's records, and the facility's policy on BP measurement and reporting was not followed in this instance.
Failure to Implement Fall Risk Interventions for Resident with Hypotension
Penalty
Summary
Facility staff failed to implement necessary interventions to reduce the risk of falls for a resident who was identified as high risk upon admission. The resident had multiple diagnoses, including atrial fibrillation and hypertension, and was admitted with low blood pressure. Upon admission, the resident was wearing a yellow bracelet indicating fall risk, and the initial blood pressure reading was significantly below the facility's defined threshold for hypotension. Despite these indicators, there was no documentation that the resident's physician was notified of the low blood pressure, nor were additional interventions implemented to address the increased fall risk. On the day of the incident, the resident's Fall Risk Evaluation score was 13, confirming high risk status, and the resident required moderate to substantial assistance for mobility and toileting. Later that evening, the resident attempted to use a urinal located on the right side of the bed and slid off the bed onto the floor. At the time of the fall, the resident's blood pressure remained critically low, and subsequent monitoring showed persistently low readings. The resident reported occasional dizziness and spinning sensations when turning, although did not recall feeling dizzy immediately before the fall. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the resident's fall risk and low blood pressure, but acknowledged that the physician was not notified and that monitoring and interventions were not initiated prior to the fall. Review of facility policies indicated that hypotension and fall risk should prompt evaluation and communication with the physician, but these steps were not documented or carried out in this case.
Failure to Implement and Document Physician-Ordered Toe Fracture Treatment
Penalty
Summary
A resident with multiple diagnoses, including disorders of bone density and muscle wasting, was admitted to the facility and later sustained an acute fracture of the left first toe, as confirmed by x-ray. The physician ordered the first toe to be taped to the second toe until an orthopedic consult, and the orthopedic specialist subsequently recommended buddy taping or splinting the toe for four to six weeks. However, there was no documentation indicating that the toe was taped as ordered, nor was there evidence that the orthopedic recommendations were transcribed into physician orders or followed after the consult. During observations and interviews, staff were unable to confirm if or when the resident's toes were taped, and the nurse did not transcribe the orthopedic recommendations into the resident's orders. The facility's policies required documentation of treatments and adherence to physician orders, but these were not followed in this case. The lack of documentation and failure to implement the prescribed treatment had the potential for the resident's injury to worsen.
Plan Of Correction
Immediate corrective action: Following observations on 6/20/2025, resident 1's toe was checked and buddy taped. Treatment records were updated, and staff in-serviced to ensure checking and taping were completed per the order summary report. Identifying other potentially affected: On 6/23/2025, the DON and Medical Records conducted a random review of three residents having treatment orders and observations. Audits and physical observation revealed successful evidence of completion. No additional concerns were noted. Measures for systemic change: Between the dates of 6/23/2025 and 6/27/2025, the DON provided in-services to licensed nurses regarding carrying out physician orders and proper completion of buddy taping and documentation of doing so for Resident 1's left toes. Monitoring for compliance: The DON and/or RN Supervisor will visually check Resident 1's toe for proper buddy taping regularly until follow-up physician orders discontinue the need. Successful completion of items above:
Failure to Provide Timely and Consistent Wound Care Leads to Infection
Penalty
Summary
A resident was admitted to the facility with a history of multiple left hip surgeries, including a recent procedure that resulted in a large surgical wound. Upon admission, the admitting RN failed to conduct a complete wound assessment and did not document the presence or condition of the surgical wound in the clinical admission record. Additionally, the RN did not obtain a treatment order for the wound at the time of admission, leaving the wound uncovered and without prescribed care for ten days. The facility's policies required a thorough admission assessment, including skin and wound evaluation, and prompt communication with the attending physician to obtain necessary treatment orders, but these steps were not followed. After a treatment order was eventually obtained, there were further lapses in care. On three consecutive days, the assigned LVNs did not implement the prescribed wound care treatment, as evidenced by blank entries in the medication administration record and confirmation from staff interviews. The wound dressing was not changed during this period, and the wound was left unattended, contrary to the treatment plan. The wound care specialist later confirmed that the wound had not been properly managed and that the dressing had not been changed for several days. As a result of these failures, the resident's surgical wound developed an infection, which was confirmed by laboratory testing and medical evaluation after the resident was transferred to an acute care hospital. The infection was attributed to inconsistent and inadequate wound care, including the lack of a timely treatment order and missed dressing changes. The facility's own staff, including the DON, wound care specialist, and infection preventionist, acknowledged that the required assessments and treatments were not performed according to policy, and that these omissions contributed to the resident's wound infection.
Failure to Document and Maintain Accurate Wound Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted with a surgical wound on the left hip. Upon admission, the responsible RN did not document the presence or description of the resident's left hip wound in the clinical admission record, despite the resident's history and physical indicating a healing wound and the Minimum Data Set noting the need for surgical wound care. The RN confirmed that wound assessments, including descriptions and measurements, should be documented at admission to allow for proper monitoring. Additionally, facility staff did not document the description or measurements of the resident's left hip wound in the long-term care evaluations on multiple subsequent dates. The Director of Nursing acknowledged that staff should have included this information in the evaluations. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but this was not followed, resulting in incomplete and inaccurate records for the resident.
Failure to Include Wound Treatment Order in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a healing surgical wound on the left hip. The resident had diagnoses including acute osteomyelitis of the left femur, infection and inflammatory reaction due to an internal left hip prosthesis, and dysphagia. Upon review, it was found that the resident required surgical wound care and was dependent on staff for several activities of daily living. Despite these needs, the care plan did not include a treatment order for the left hip wound until nearly two months after admission. Interviews with nursing staff confirmed that a treatment order for the surgical wound was not obtained at the time of admission, and the care plan initially failed to address this critical intervention. The facility's policy required that care plans include measurable objectives and timetables to meet each resident's needs, and that all residents with wounds have a wound treatment order included in their care plan. The omission of the wound treatment order in the care plan was identified during record review and staff interviews.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to obtain informed consent from the responsible party prior to administering a psychoactive medication, Seroquel, to a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson's disease, dementia, and a history of falls, was unable to make medical decisions. Despite this, Seroquel was ordered and administered for psychosis manifested by visual hallucinations and aggression, without documented evidence that the responsible party was informed of the risks and benefits or that consent was obtained. Record reviews confirmed that the medication was given on multiple occasions, and both the LVN and DON acknowledged that informed consent was required for psychotropic medications, as per facility policy. The facility's policy specified that the physician must inform the resident or representative and obtain consent before use of such medications. The lack of documented consent meant the responsible party was not given the opportunity to make an informed decision regarding the resident's treatment.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified during the Monthly Drug Regimen Review (MDRR) by the facility's pharmacist were acted upon for one resident. Specifically, the pharmacist made recommendations regarding the continued use of gastrointestinal medications (Famotidine and Pantoprazole), the reconsideration of Simvastatin, and a gradual dose reduction for the antipsychotic medication Seroquel. In each instance, there was no documentation that the resident's physician was informed of the pharmacist's recommendations or that any action was taken in response. Record reviews showed that the pharmacist's notes to the attending physician regarding these medications were left blank in the section for the physician's response, indicating no documented agreement or disagreement with the recommendations. Interviews with facility staff, including a hospice RN, RN supervisor, and the DON, confirmed that the pharmacist's recommendations were not communicated to the physician as required. The facility's policy states that such irregularities should be reported to the physician within a specified timeframe and that the physician should document their review and actions taken. The resident involved had significant cognitive impairment and multiple diagnoses, including dementia with psychotic disturbances, anxiety, and depression. The lack of follow-through on the pharmacist's recommendations resulted in the potential for unnecessary medication administration, as there was no evidence that the physician was made aware of or addressed the identified medication irregularities.
Failure to Follow Infection Control Practices and Proper Handling of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several instances involving two residents. For one resident with multiple diagnoses, including pressure-induced deep tissue damage and congestive heart failure, staff did not follow Enhanced Barrier Precautions (EBP) as required. Despite signage indicating the need for gloves and gowns during high-contact care activities, a certified nurse assistant was observed providing face hygiene care without wearing any personal protective equipment (PPE). Both the Infection Preventionist Nurse and the Director of Nursing confirmed that PPE should have been used for residents on isolation precautions. Additionally, the facility did not ensure that nasal cannula (NC) tubing used for oxygen delivery was kept off the floor for two residents. One resident, who was dependent for personal hygiene and had an order for continuous oxygen, was observed with their NC touching the floor while in bed. The attending licensed vocational nurse acknowledged that this was inappropriate for infection control. Similarly, another resident with intact cognition and an as-needed oxygen order was found with their NC tubing on the floor. The nurse present and the Director of Nursing both recognized this as an infection control risk and stated that the tubing should be replaced. A review of facility policies indicated that oxygen delivery devices must be kept clean and changed as needed, and that PPE is required during certain care activities to prevent exposure to bodily fluids. The facility's in-service training also emphasized the importance of proper storage of personal belongings to prevent contamination. These observations and interviews demonstrate lapses in adherence to established infection control protocols, specifically regarding the use of PPE and the handling of oxygen delivery equipment.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident with severe visual impairment and failed to answer a call light in a timely manner for another resident. In the first instance, a resident who was legally blind and dependent on staff for activities such as toilet hygiene and bathing was observed sitting in a wheelchair beside the bed, with the call light placed in the middle of the bed and out of reach. The resident expressed difficulty in locating the call light due to blindness and stated a desire to have it within reach. Staff interviews confirmed the resident's blindness and the expectation that the call light should be accessible, especially for residents with visual impairments. Facility policy also indicated that call lights should be accessible to residents. In the second instance, a resident with diagnoses including a stage 3 pressure ulcer, diabetes, and dysphagia, and who had intact cognition, activated the call light for assistance with treatment. The call light outside the resident's room and at the nursing station remained lit and unanswered for approximately 11 minutes before being addressed by a nurse. The resident reported dissatisfaction with the wait time. Staff interviews confirmed that call lights should be answered within three to five minutes, with a maximum of ten minutes, and that both licensed and unlicensed staff are responsible for responding. Facility policy supported the expectation for prompt response to call lights.
Incorrect MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. The resident, who had a history of hemiplegia, hemiparesis following a cerebral infarction, diabetes mellitus, and generalized muscle weakness, was admitted and had an order for Plavix (clopidogrel), an antiplatelet medication, to be administered daily for a cerebrovascular accident. The MDS, dated shortly after admission, incorrectly indicated that the resident received anticoagulant medication. During interviews and record reviews, it was clarified by the MDS Nurse that Plavix is classified as an antiplatelet, not an anticoagulant, and should not have been coded under the anticoagulant section (N0415E) of the MDS. The DON confirmed that accurate medication documentation on the MDS is essential for proper care planning and that anticoagulant and antiplatelet medications are coded separately due to their different mechanisms and uses. The CMS RAI User's Manual also specifies that antiplatelet medications should be coded distinctly from anticoagulants.
Inaccurate MDS Assessment of Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's hospice status. The resident was admitted with diagnoses including heart failure, depression, and anxiety disorder, and had an active physician order for hospice care from the time of admission. The resident's care plan and order summary both indicated hospice care, and interviews with the resident, a Licensed Vocational Nurse, and the MDS Coordinator confirmed that hospice services had been provided since admission. However, the MDS assessment did not indicate that the resident was on hospice care while residing in the facility. This discrepancy was identified during a review of the resident's records and confirmed through staff interviews. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, and federal regulations mandate that the assessment accurately reflect the resident's status. The inaccurate coding of the MDS assessment resulted in a failure to properly document the resident's hospice status.
Failure to Explain Medications Prior to Administration
Penalty
Summary
The facility failed to ensure that medications, their purposes, and potential side effects were explained to a resident prior to administration. During an observation, an LVN administered multiple medications to a resident without providing explanations about the medications, their intended uses, or possible side effects. The resident, who had diagnoses including pulmonary embolism, diabetes mellitus, and dementia, was documented as lacking capacity to understand and make decisions, and required substantial to maximal assistance with activities of daily living and was dependent for mobility. Interviews with the LVN, the resident, and the Director of Nursing confirmed that the practice of explaining medications prior to administration was not followed in this instance. The resident expressed a desire to know what medications were being given and their purposes, stating it would have reduced confusion and provided a sense of choice. Facility policies reviewed indicated that residents have the right to be informed about their care and to participate in care planning and treatment, as well as to be treated with dignity and respect.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, asthma, and dysphagia did not receive oxygen therapy in accordance with the physician's order. The resident was ordered to receive continuous oxygen at three liters per minute via nasal cannula, with the care plan specifying that the oxygen flow should be checked every four hours. However, during an observation, the resident was found to be receiving four liters per minute. The attending LVN confirmed the discrepancy and adjusted the oxygen flow to the ordered amount. Record reviews showed that documentation indicated the resident was receiving the correct amount of oxygen and that checks were being performed as required, but direct observation contradicted this. Interviews with nursing staff and the DON confirmed that oxygen administration should follow the physician's order and that only licensed nurses are permitted to adjust oxygen levels. Facility policies also required staff to verify and set oxygen delivery to the prescribed flow rate.
Failure to Implement Physician Order for Bilateral Floor Mats
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for floor mats to be placed on both sides of a resident's bed. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of repeated falls, was assessed as having severely impaired cognitive skills and required substantial to maximal assistance with activities of daily living and was dependent for mobility. During observation, only one safety mat was found on the left side of the bed, despite the physician's order and care plan specifying floor mats on both sides to prevent injury in the event of a fall. Interviews with facility staff, including an LVN and the DON, confirmed that the physician's order for bilateral floor mats was not followed. The care plan and job descriptions for both LVNs and RNs indicated the requirement to comply with physician orders and implement care plans. The failure to place floor mats on both sides of the bed was directly observed and verified through record review and staff interviews.
Failure to Post Accurate and Accessible Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual nursing hours for all shifts on specified dates and did not ensure that the staffing information was displayed in a prominent location accessible to residents and visitors. Observations revealed that the staffing sheet was only posted at the nursing station and not in an area readily accessible to residents and visitors. Additionally, the posted staffing information did not include the total and actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. Interviews with the Staffing Assistant and the Director of Nursing confirmed that the only nursing staffing postings were at the nursing station and that actual hours worked per shift were not posted as required. The facility's policy indicated that nurse staffing data, including actual hours worked, should be posted daily for each shift in a prominent location. However, this was not followed, resulting in nurse staffing information being inaccessible to visitors and lacking required details.
Deficient Food Storage and Incomplete Sanitation Logs
Penalty
Summary
The facility failed to ensure proper food storage and maintain sanitary conditions in the kitchen. During an observation, five beef base containers labeled with a past best if used by date were found stored in a walk-in refrigerator. The dietary supervisor confirmed that food past its use-by date should not be stored and should be discarded to prevent potential foodborne illness, in accordance with the facility's policy and procedure. The policy specifically states that foods past the use by, sell-by, best-by, or enjoy by date should be discarded to maintain food safety and prevent contamination. Additionally, a review of kitchen logs revealed incomplete documentation for sanitation and equipment cleaning. The sanitation bucket log lacked records for several time points and was missing the manager's initials in the weekly review section. The ice machine cleaning log showed the ice machine was not cleaned as required, and the dish machine temperature record was missing checks and manager initials. The dietary supervisor acknowledged the importance of accurate and daily completion of these logs for regulatory compliance, infection control, and quality assurance, as outlined in the facility's policies.
Inaccurate Documentation of Discharge Disposition
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's discharge disposition in the medical record. A review of the resident's records showed inconsistencies: the Admission Record indicated admission with diagnoses including atrial fibrillation, shortness of breath, and muscle weakness. The Discharge Planning Review noted the resident requested discharge to another LTC center, and the Discharge Instruction Form confirmed discharge to a LTC center. However, the Minimum Data Set (MDS) documented the resident as being discharged to a short-term general hospital. During interviews, the MDS Coordinator acknowledged incorrectly documenting the discharge destination in the MDS, while the Discharge Instruction Form reflected the correct LTC center destination. The Director of Nursing confirmed that accurate documentation in the medical record is essential for quality care and impacts the development of the care plan and post-discharge support. The facility's policy requires that documentation be objective, complete, and accurate. The discrepancy between the MDS and the Discharge Instruction Form resulted in incomplete and potentially misleading information regarding the resident's discharge status.
Failure to Monitor RSV Exposure Among Staff and Residents
Penalty
Summary
The facility failed to investigate and monitor healthcare personnel for signs and symptoms of Respiratory Syncytial Virus (RSV) after exposure to two residents who tested positive for RSV. Resident 1 was admitted with hypertensive heart disease and chronic kidney disease, and tested positive for RSV after exhibiting cough symptoms. Resident 2, admitted with dependence on supplemental oxygen and muscle weakness, also tested positive for RSV. Both residents were placed on isolation after their positive test results. However, the Infection Prevention Nurse (IPN) did not maintain a list of staff or residents who had close contact with the infected residents, and the Director of Nursing (DON) confirmed that there was no tracking of such contacts. The facility's policy and procedure for infection control lacked procedures for tracking close contacts or potential exposures. The IPN was unaware if two staff members who called off work due to not feeling well had close contact with the infected residents. The facility's failure to track and monitor close contacts of the infected residents was contrary to the CDC's guidelines, which recommend active surveillance to identify additional ill residents or healthcare personnel. This deficiency had the potential to spread RSV to other residents and staff within the facility.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain its infection prevention and control program for two sampled residents by not ensuring proper hand hygiene during meal service. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before entering Resident 1's room, after assisting with the lunch tray, or after exiting the room. Subsequently, CNA 1 handled a coffee pot at a shared station without performing hand hygiene and then entered Resident 2's room to provide a coffee cup, again without performing hand hygiene. This sequence of actions had the potential to transmit infectious microorganisms between residents. Resident 1 was admitted with diagnoses including a left femur fracture, gastrointestinal hemorrhage, and muscle wasting, with moderately impaired cognition and dependency on assistance for activities of daily living. Resident 2 had a history of myocardial infarction, urinary tract infection, and difficulty walking, with decision-making capacity dependent on context. The facility's policy required handwashing before and after direct resident care and contact with potentially contaminated substances, which was not adhered to in this instance, as confirmed by interviews with CNA 1 and the Infection Preventionist Nurse.
Inaccurate Infection Monitoring Form During Influenza Outbreak
Penalty
Summary
The facility failed to accurately complete the infection monitoring form during an influenza outbreak for a resident. The deficiency was identified during a review of the resident's Admission Record, which indicated that the resident was admitted on 12/16/2024 with diagnoses including influenza, pneumonia, and respiratory failure. However, the Infection Monitoring Forms dated 12/13/2024 and 12/14/2024 inaccurately indicated that the resident was already in the facility and showing symptoms of a cough, despite the resident not being admitted until 12/16/2024. During an interview with the Director of Nursing (DON), it was revealed that the infection monitoring in the facility was not initiated until 12/17/2024 for all residents, and the dates on the forms were inaccurately completed. The DON acknowledged the importance of ensuring that forms are accurately completed in healthcare, as they directly impact patient care, safety, compliance, and operational efficiency. The facility's policy and procedure on Charting and Documentation, dated 7/2017, emphasized that documentation in the medical record should be objective, complete, and accurate.
Failure to Revise Care Plans After Multiple Falls
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding falls management and care plan revisions, resulting in a deficiency. Specifically, the facility did not revise the care plans or implement new interventions for two residents after they experienced multiple falls. Resident 1, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had several falls documented on SBAR Communication Forms. Despite these incidents, there were no revisions made to Resident 1's care plan to address the falls. Similarly, Resident 2, who was admitted with Parkinson's disease and dementia, also experienced multiple falls as documented on SBAR forms. The facility's records showed that no care plan revisions or new interventions were implemented following these falls. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that care plans should be revised after each fall, but this was not done for Residents 1 and 2. The facility's policies and procedures, including the Falls Management Program and Comprehensive Person-Centered Care Plans, emphasize the need for ongoing assessments and care plan revisions when there is a significant change in a resident's condition. The failure to revise care plans and implement new interventions after falls placed the residents at risk for further falls and injuries, as the facility did not follow its established protocols to mitigate these risks.
Incomplete Documentation of Resident's Urology Consult
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Charting and Documentation,' resulting in incomplete documentation for a resident. The resident, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had a scheduled urology consult that was not documented in the medical records. The absence of documentation regarding the cancellation of the urology consult appointment led to a lack of communication among facility staff about the resident's care. Interviews with facility staff revealed that the cancellation of the urology consult was known but not recorded in the resident's chart. Both a Licensed Vocational Nurse and Social Services staff acknowledged the importance of documenting such changes to ensure all staff are informed about the resident's care status. The facility's policy requires that all services, progress, and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Report Hepatitis A Case to CDPH
Penalty
Summary
The facility failed to report a communicable disease, specifically Hepatitis A, to the California Department of Public Health (CDPH) for a resident who tested positive. The resident, who had been admitted to the facility with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, was found to have a high level of Hepatitis A antibodies during a test conducted at a general acute care hospital. The hospital's infection preventionist informed the facility of the positive test result, but the facility only reported the case to the County of Los Angeles Department of Public Health and not to the CDPH. The Director of Nursing (DON) admitted during interviews that they were unaware of the requirement to report the case to the CDPH. The facility's policy and procedure documents, which were reviewed, indicated that unusual occurrences, such as outbreaks of communicable diseases, should be reported to appropriate agencies within 24 hours. However, the facility did not follow this protocol in the case of the resident with Hepatitis A. The failure to report the disease to the CDPH had the potential to hinder proper and timely investigation of the communicable disease.
Infection Control Deficiencies in Covid-19 Isolation Area
Penalty
Summary
The facility failed to implement proper infection control practices to prevent the spread of Covid-19. A housekeeper entered a Covid-19 isolation room without wearing the required eye protection, such as a face shield or goggles, as indicated by the signage outside the room. This signage, provided by the County of Los Angeles Public Health, specified that personal protective equipment, including eye protection, must be worn before entering the room. The housekeeper acknowledged not wearing the necessary eye protection, which is a breach of the facility's policy on standard precautions. Additionally, three tumbler cups belonging to staff were found on the handrail in the red zone, an area designated for residents who tested positive for Covid-19. The Infection Preventionist Nurse confirmed that these cups should not be left on the handrails due to the risk of cross-contamination, which could potentially lead to the spread of infection throughout the facility. The facility's in-service training on infection control emphasized the importance of proper storage of personal belongings, indicating that items such as coffee cups and water bottles should not be left in hallways or resident areas.
Failure to Answer Call Lights Promptly
Penalty
Summary
The facility failed to answer call lights in a timely manner for seven residents, leading to frustration and potential psychosocial decline. Resident 2, who was dependent on staff for toileting, dressing, and bathing, reported waiting up to an hour for assistance, causing frustration and self-reliance for bathroom needs. Resident 15, who required substantial assistance, was observed waiting 15 minutes for help with a bedpan, and Resident 31 reported waiting more than 10 minutes for call light responses, which they considered too long. Resident 148, who was dependent on staff for various needs, reported waiting one to two hours for assistance, leading to prolonged periods in soiled briefs and concerns about skin health. Resident 149's representative stated that the resident, who had bowel issues, waited 15 minutes for call light responses, resulting in incontinence and the need for frequent clothing changes. Resident 150 also reported waiting up to an hour for assistance with soiled briefs, and Resident 30 mentioned that staff often promised quick returns but did not follow through. Interviews with staff, including CNA 1 and the DON, revealed that staffing shortages and increased resident assignments contributed to the delays. The DON acknowledged that call lights should be answered within 5 to 10 minutes and that longer waits could lead to urinary tract infections, skin breakdown, and negative impacts on residents' dignity and psychosocial well-being. Facility policies emphasized the importance of prompt call light responses to maintain resident dignity and care standards.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential gaps in their care. For Resident 16, who was diagnosed with dementia and unspecified psychosis, the facility did not create a care plan to address the use of Depakote Sprinkles, a medication prescribed for bipolar mania. This omission was confirmed during an interview with an LVN, who acknowledged that a care plan was required to monitor the medication's effectiveness and potential adverse reactions. For Resident 25, who had diagnoses including Type 2 Diabetes and dysphagia, the facility did not individualize the care plan to address the resident's nutritional needs and difficulty chewing. Despite a recommendation from a Registered Dietician for a puree diet due to dental issues, the care plan remained generalized and did not reflect specific weight goals or interventions. Both the RD and an LVN confirmed that the care plan should have been tailored to meet the resident's specific needs. Resident 11, who had severe cognitive impairment and was dependent on assistance for daily activities, had a care plan for the risk of altered fluid balance that lacked measurable objectives and timeframes. The Director of Nursing acknowledged that the care plan needed to be individualized to help the resident maintain optimal functioning. The facility's policy and procedure on care plans emphasized the need for measurable objectives and timeframes, which were not met in these cases.
Failure to Follow Physician's Orders for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that Resident 46 received treatment and care in accordance with professional standards of practice by not following the physician's orders for the administration of antihypertensive medications. Specifically, the facility did not adhere to the prescribed parameters for holding medications based on the resident's blood pressure readings. On multiple occasions, Losartan and Metoprolol were administered despite the resident's blood pressure being below the threshold specified in the physician's orders, which could have adversely affected the resident's health status. Resident 46, who had a history of essential hypertension, hypertensive heart disease with unspecified congestive heart failure, and unspecified atrial fibrillation, was admitted to the facility with specific medication orders. The orders included holding Losartan if the systolic blood pressure (SBP) was less than 120 mmHg and holding Metoprolol if the SBP was less than 100 mmHg or the heart rate was less than 60 beats per minute. However, the Medication Administration Record (MAR) indicated that these medications were administered even when the resident's blood pressure readings were below the specified parameters. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the medications were given incorrectly on several dates, including 2/19/24, 2/24/24, 2/5/24, 2/23/24, and 2/26/24. The facility's policies and procedures for medication administration were not followed, as the staff did not check the physician's orders and parameters prior to administering the medications. This failure to follow the prescribed orders had the potential to result in harmful changes to the resident's blood pressure, compromising their health and safety.
Staffing Shortages Lead to Delayed Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide sufficient staffing, resulting in delayed toileting and incontinence care for seven of 16 sampled residents. This deficiency was observed through multiple interviews, record reviews, and direct observations. Residents reported waiting times ranging from 10 minutes to over an hour for assistance with toileting and changing soiled briefs. These delays were corroborated by staff interviews, which revealed that staffing shortages and call-offs contributed to the prolonged response times. The Director of Nursing (DON) acknowledged that call lights should be answered within 5 to 10 minutes, and delays could lead to urinary tract infections (UTIs) and skin breakdowns. Resident 2, who was admitted with diagnoses including congestive heart failure and dysphagia, reported waiting up to an hour for assistance, leading to self-toileting despite fall risks. Resident 15, with hypertension and legal blindness, waited 15 minutes for help with a bedpan. Resident 30, diagnosed with Parkinson's disease and dementia, also experienced long waits for assistance. Resident 31, with a history of UTIs, reported similar delays. Resident 148, who had a lumbar vertebra fracture, waited up to two hours for help with changing wet briefs, causing discomfort and potential skin issues. Resident 149, with COPD and dementia, faced 15-minute waits, leading to incontinence incidents. Resident 150, admitted with enterocolitis due to C. diff, reported waiting up to an hour for brief changes, resulting in sore and irritated skin. Staff interviews confirmed the facility's staffing issues. CNA 1 and CNA 2 mentioned that call-offs and increased resident assignments led to longer wait times for residents. LVN 1 expressed emotional distress due to the staffing shortage, noting that new hires often did not stay. The facility's policies indicated that call lights should be answered within 3-5 minutes, with a maximum wait time of 10 minutes. The facility assessment highlighted the need for prompt response to bowel/bladder services to maintain continence and promote resident dignity. However, the observed delays and staff admissions indicated a failure to meet these standards, resulting in compromised resident care.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to follow safe and proper food storage and preparation practices in the kitchen, as observed during a survey. Specifically, food items were found unlabeled and undated, including a jar of peanut butter, individual servings of chocolate pudding, containers of cut-up fresh fruits, dinner rolls, and bins of yellow and red onions. The Utility Worker (UW) acknowledged that the facility's practice was to label food items immediately upon opening to prevent serving spoiled food that could make residents sick. Additionally, cold foods such as macaroni salad were not maintained at the required temperature of 41 degrees Fahrenheit or below, with observed temperatures of 44 and 45 degrees Fahrenheit. The Executive Chef (EC) confirmed the importance of maintaining proper food temperatures to ensure food safety and quality for residents. The facility's policies and procedures (P&P) for food and supply storage, as well as refrigerated storage life of foods, were reviewed and indicated the necessity of labeling and dating food items and maintaining cold food temperatures at 41 degrees Fahrenheit or below. However, the facility's Temperature Log and Checklist (TLC) did not consistently document food items with corresponding temperatures, and cold items were not always placed on ice as required. The deficiencies observed in food labeling and temperature control had the potential to cause foodborne illness and affect the quality and palatability of food served to residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow standard infection control practices by not safely and hygienically storing personal toiletries and belongings for two residents. Resident 9, who had diagnoses including myocardial infarction, type 2 diabetes mellitus, and end-stage renal disease, had an unlabeled electric toothbrush and other personal items stored improperly in a shared restroom. Similarly, Resident 98, who had heart failure, type 2 diabetes mellitus, and unspecified psychosis, also had personal items stored in an unhygienic manner. Certified Nursing Assistant 5 confirmed that the items should have been labeled and stored separately to prevent cross-contamination. The Infection Preventionist also emphasized the importance of labeling personal belongings to avoid confusion and potential cross-contamination. Additionally, the facility did not have a surveillance plan to monitor or track infections other than COVID-19. The Director of Nursing admitted that the facility did not track or monitor infections and relied on the public health nurse for advice when a resident had a communicable disease. This lack of tracking and monitoring could potentially lead to the spread of infections within the facility. The facility's policy indicated that the Infection Preventionist should maintain documentation of incidents, findings, and corrective actions, and report surveillance findings to the Quality Assessment and Assurance Committee.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, identified as Resident 28, as indicated in the resident's care plans. Resident 28, who had diagnoses including muscle weakness, unspecified glaucoma, and Alzheimer's disease, was observed sitting in a recliner chair with the call light device looped around the left side rail of the bed, out of reach. Certified Nursing Assistant 3 confirmed that Resident 28 could not reach the call light device and subsequently placed it within reach. Interviews with staff members, including the MDS Assistant and another CNA, emphasized the importance of having the call light within reach for resident safety and the ability to call for help. Resident 28's care plans, which addressed risks for falls, communication problems, and anxiety, all indicated the necessity of having the call light within reach. The facility's policy and procedure on call lights also required that the call light be available to residents and that staff respond promptly to requests. Despite these guidelines, the call light was not initially placed within reach, potentially compromising Resident 28's ability to alert staff for assistance in a timely manner.
Failure to Ensure Resident's Treatment Wishes Documented
Penalty
Summary
The facility failed to ensure that Resident 9 had directions or instructions regarding treatment requests and wishes in the event of a medical emergency, as indicated in the facility's Policy and Procedure (P&P) and Resident 9's care plan. Resident 9's Admission Record indicated diagnoses including a subsequent non-ST elevation myocardial infarction, type 2 diabetes mellitus, and end-stage renal disease. Despite having an intact cognitive status, Resident 9 did not have a completed Physician Orders for Life-Sustaining Treatment (POLST) form or an advance directive (AD). The POLST form was incomplete and lacked signatures from both Resident 9 and a physician, which was confirmed during interviews with the Social Services Designee (SSD) and a Registered Nurse (RN). Both staff members acknowledged the importance of having a completed POLST or AD to ensure the resident's treatment wishes are honored in a medical emergency. Resident 9 stated that the facility did not discuss their treatment requests or wishes in the event of a medical emergency. The care plan for Resident 9, which indicated a Full Code status, required that the code status be signed by the resident or responsible party and be included in the active medical record. The facility's P&P on POLST forms, revised in 2018, also required that the form be signed by both the resident and a physician. The failure to complete the POLST form and discuss treatment wishes with Resident 9 had the potential for the resident to receive inappropriate or medically unnecessary care, treatment, and services.
Inaccurate MDS Documentation for a Resident
Penalty
Summary
The facility failed to ensure that Resident 35's Minimum Data Set (MDS) was completed accurately. Resident 35 was initially admitted with diagnoses including anxiety disorder, muscle weakness, and essential hypertension. The MDS dated [DATE] incorrectly indicated that Resident 35 was receiving oxygen therapy and tracheostomy care. However, during an observation and interview, it was confirmed that Resident 35 did not have a tracheostomy or a breathing tube. The MDS Assistant and the Director of Nursing (DON) both confirmed that the MDS was incorrect and not accurate, as Resident 35 did not have a tracheostomy and should not have been coded as such. The facility's undated Policy and Procedure (P&P) titled
Failure to Maintain Bed in Low Position for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's bed was maintained in a low position, which is a critical intervention to prevent falls. Resident 40, who had a history of multiple falls and was at high risk for further falls, was observed on multiple occasions with their bed not in the lowest position. This failure occurred despite clear documentation in the resident's care plan and orders that the bed should be kept in the lowest position to minimize injury in case of a fall. The resident's medical history included cerebral infarction, muscle weakness, dementia, and severe cognitive impairment, all of which contributed to their high fall risk. On several documented instances, including an unwitnessed fall that resulted in a pneumothorax, the resident's bed was found to be elevated. Staff interviews confirmed that the bed should have been kept in the lowest position, and observations during the survey corroborated that this intervention was not consistently followed. The facility's policy on fall management also emphasized the importance of maintaining the bed in its lowest position as a preventive measure, yet this was not adhered to, placing the resident at risk for further falls and injuries.
Failure to Provide Timely Colostomy Care
Penalty
Summary
The facility failed to follow the physician's order to check the colostomy site every shift and change the leaky colostomy bag in a timely manner for a resident who required colostomy care. The resident, who had no cognitive impairments and was dependent on staff for bathing and dressing, reported that the colostomy bag was leaking and that the facility did not have the necessary supplies to reattach a new colostomy bag. The resident expressed frustration, stating that they had been requesting the supplies for three weeks. An observation confirmed that the colostomy flange was not secured to the resident's skin and was soiled with stool, and the supplies were still en route to the facility at that time. The Registered Nurse (RN) confirmed that the colostomy bag needed to be changed on a previous date but could not be due to the lack of supplies. The Director of Nursing (DON) also stated that colostomy bags should be changed if they are leaking or soiled. The resident's care plan indicated that staff were to ensure appropriate wafer stoma size and adhesive and provide colostomy care every shift. The facility's policy and procedure for colostomy care outlined the necessary equipment and supplies, which were not available at the time of the incident, leading to the deficiency in care for the resident.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that Resident 10 received oxygen therapy consistent with professional standards of practice and in accordance with the physician's order. Resident 10, who was admitted with diagnoses including heart failure, unspecified dementia, and shortness of breath, had an order for continuous oxygen at three liters through a nasal cannula. However, during an observation, it was found that Resident 10 was receiving oxygen at 4 1/2 liters, contrary to the physician's order. This discrepancy was confirmed by both Resident 10's Responsible Party and a Registered Nurse, who acknowledged the importance of adhering to the prescribed oxygen flow rate. The facility's Policy and Procedure for Oxygen Administration, revised in October 2010, mandates verifying and reviewing the physician's orders for oxygen administration and ensuring the proper flow of oxygen is being administered. Despite this policy, the facility did not comply, as evidenced by the incorrect oxygen flow rate observed. This failure to follow the prescribed oxygen therapy could potentially compromise Resident 10's medical condition, highlighting a significant lapse in the facility's adherence to professional standards and physician orders.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication. Resident 30 had an order for Lorazepam without an end date within 14 days from the time it was ordered, which is against regulations. The resident was admitted with diagnoses including Parkinson's disease, dementia, and anxiety disorder. The Minimum Data Set indicated that the resident had mildly impaired cognition. Despite a recommendation from the Consultant Pharmacist to discontinue the Lorazepam order to comply with regulations, the order was not discontinued because the resident's family wanted to keep the medication available. The Medication Administration Record showed that Lorazepam was not administered during the review period, but the order remained active without proper re-evaluation for unnecessary medication use. During an interview, the Director of Nursing acknowledged that not following pharmacy recommendations would result in the resident not being re-evaluated for unnecessary medications. The facility's policy on Medication Monitoring and Management requires a documented clinical rationale if the prescriber deems the medication necessary, but this was not followed in Resident 30's case. This failure had the potential for the resident to receive unnecessary psychotropic medication, which could result in adverse consequences.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed the specialized training required for the role, as indicated in the facility's job description. During an interview, the IP admitted to being on module five of 24 in the certification process and had not yet completed the necessary training. The Director of Nursing (DON) confirmed that the IP was still in training and that the DON was assisting with IP duties in the interim. The facility's job description for the IP role specified that the IP should have completed specialized training in infection prevention and control, which had not been fulfilled at the time of the survey.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to prevent a fall for a resident with a history of falls by not implementing the physician's order to place bilateral floor mats and a silent bed/chair alarm. The resident, who had muscle weakness, falls, and gait abnormalities, was admitted with an active order for these safety measures. Despite this, the resident fell and sustained a right femoral neck fracture, requiring surgical intervention and hospitalization. The resident's care plan and assessments indicated a high risk for falls, and the use of floor mats and bed/chair alarms were documented as necessary interventions. However, during the incident, these safety measures were not in place. The resident fell while attempting to use the restroom, resulting in a hip fracture. Staff interviews confirmed that the required safety devices were not present at the time of the fall. The facility's policies on silent pad alarms and fall management were not followed, as the ordered safety devices were not implemented. The failure to adhere to these orders and policies directly led to the resident's fall and subsequent injury. Staff members acknowledged the absence of the required safety measures, indicating a lapse in compliance with the physician's orders and facility protocols.
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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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