Citations in California
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in California
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident experienced low pulse rates and poor oral intake over several days, but nursing staff did not complete follow-up assessments, notify the physician, or document interventions as required by facility policy. The DON confirmed that abnormal vital signs and poor meal intake were not consistently treated as significant changes of condition, resulting in a lack of timely clinical response.
A CNA did not wear the required gown and gloves while providing high-contact care to a resident with a central line, despite facility policy and a physician's order for enhanced barrier precautions. Signage outside the room did not indicate the need for these precautions for the resident, and staff interviews confirmed the oversight in both PPE use and updating of precaution signage.
Two residents who used bilateral grab rails had their bed rail entrapment assessments inaccurately completed, with all seven zones marked as 'pass' instead of correctly identifying which zones were applicable. The maintenance supervisor used incorrect measurement methods, and both the DON and maintenance supervisor confirmed the assessments were not done according to policy or FDA guidance.
A resident with limited English proficiency, who primarily spoke Cantonese and Vietnamese, was not provided with effective communication accommodations. Despite facility policies, staff did not provide a communication board in the resident's room or utilize interpreter services, resulting in the resident relying on family members to communicate needs. Staff were unable to demonstrate knowledge or use of translation resources, and the absence of these accommodations had the potential to impact the resident's psychosocial well-being and delay care.
A resident admitted with a physician's order for apixaban to treat atrial fibrillation did not have a care plan developed to address the use of this anticoagulant medication. Multiple staff, including an RN, LVN, MRD, and MDS Coordinator, confirmed the absence of a care plan, despite facility policy requiring comprehensive, person-centered care plans for each resident. The lack of a care plan was verified through medical record review and staff interviews.
A cracked floor in a hallway, observed by surveyors and reported as unsafe by several residents and staff, was not repaired or marked with warning signs. Residents with mobility impairments and fall risks were seen traversing the area, and facility records showed no maintenance reports or actions taken, despite the facility's policy requiring safe and well-maintained flooring.
A resident with hypertension and congestive heart failure, who was cognitively intact, exhibited a sudden change in behavior by refusing care, screaming, laughing inappropriately, and kicking a staff member. Despite staff involvement and facility policy requiring physician notification for such changes, the physician was not informed of the incident.
Two residents did not receive their prescribed medications on time, and staff failed to notify the physician prior to administering the late doses. In both cases, medications scheduled for the morning were given several hours late without prior physician input, and documentation of physician notification or assessment for adverse effects was lacking. Nursing staff and the DON confirmed that the required process for physician notification was not followed.
A nurse failed to ensure that a resident with multiple medical conditions received medications according to physician orders, including not providing required food or fluids with certain medications, not instructing the resident to rinse her mouth after inhaler use, and allowing self-administration without a physician's order or proper supervision.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Assess, Notify, and Document Changes in Resident Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure the highest practicable well-being for a resident, as required by professional standards and the facility's own policies. Specifically, the facility did not complete follow-up assessments, notify the physician, or document actions taken when the resident exhibited a low pulse rate and poor oral intake. The resident's medical records showed multiple instances of bradycardia, with pulse rates below 60 bpm, and there was no evidence that these abnormal findings were followed up with appropriate clinical interventions or physician notification, as outlined in the facility's policy for changes in a resident's condition. Additionally, the resident experienced a significant decline in meal intake over several days, with documented refusals and consumption of less than 25% of meals on multiple occasions. Despite this, there was no documentation of follow-up assessments, physician notification, or care plan adjustments in response to the resident's poor nutritional intake. Interviews with nursing staff confirmed that these changes were observed and reported to charge nurses, but the required documentation and clinical follow-up were not completed. The Director of Nursing (DON) indicated that abnormal vital signs alone were not considered a significant change of condition and did not expect licensed nurses to document follow-up entries after providing interventions. The DON also stated that a significant change of condition related to meal intake would only be recognized after three to four days of consecutive low intake with refusal. These practices were inconsistent with the facility's policy and contributed to the failure to ensure timely and appropriate care for the resident.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to wear the appropriate personal protective equipment (PPE) while providing high-contact care to a resident with an indwelling medical device. The facility's policy required staff to don both gown and gloves during high-contact care activities for residents with indwelling devices, such as central lines, to prevent the transmission of multidrug-resistant organisms (MDROs). During an observation, the CNA was seen wearing only gloves while assisting the resident with morning care and transferring them to a wheelchair, despite the resident having a physician's order for enhanced barrier precautions (EBP) due to a central line for dialysis access. The signage outside the resident's room indicated that only the roommate was on EBP, and did not reflect that the observed resident also required these precautions. The registered nurse (RN) confirmed that the signage should have included the resident, as per the physician's order, and stated that the Director of Staff Development (DSD) was responsible for updating such signage. The infection prevention (IP) nurse also confirmed that staff must wear both gown and gloves for residents with EBP orders and that she was responsible for ensuring proper signage and PPE availability. Interviews with facility staff, including the CNA, RN, IP nurse, and Director of Nursing (DON), confirmed awareness of the EBP requirements and the importance of following them to prevent infection transmission. However, the failure to update signage and ensure staff compliance with PPE protocols resulted in a lapse in infection control practices for the resident with a central line. This deficiency was identified through observation, interviews, and review of facility policies and the resident's medical record.
Inaccurate Bed Rail Entrapment Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed rails were accurately and completely performed for two residents who used bilateral grab rails. According to the FDA's guidance, there are seven zones in a bed system where entrapment can occur, and the facility's policy requires regular inspection and assessment of these zones to identify potential risks. However, the entrapment assessments for both residents were incorrectly completed, with some zones marked as 'pass' when they should have been marked as 'not applicable' based on the type of bed rails in use. For one resident, who had moderate cognitive impairment and used bilateral grab rails for mobility and transfers, the assessment marked all seven zones as 'pass' even though only certain zones were relevant for the type of rails installed. Similarly, for another resident who was cognitively intact and also used bilateral grab rails, the assessment again marked all zones as 'pass' instead of correctly identifying which zones applied. The maintenance supervisor, responsible for these assessments, was found to have used an incorrect method for measuring one of the zones and confirmed that the assessments were inaccurate. Observations and interviews with staff, including the Director of Nursing and the maintenance supervisor, verified that the entrapment assessments were not completed according to the facility's policy or the FDA guidance. The inaccurate assessments had the potential to negatively impact residents by failing to properly identify and mitigate entrapment risks associated with the use of bed rails.
Failure to Provide Communication Accommodations for LEP Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with limited English proficiency (LEP) who primarily spoke Cantonese and Vietnamese. Despite facility policies requiring language assessments, notification of language access coordinators, and provision of communication aids such as interpreters and communication boards, the resident was not provided with effective means to communicate daily needs. Observations and interviews revealed that the resident could not effectively communicate with staff due to the absence of staff who spoke her language, lack of a communication board in her room, and no use of telephone translation services by staff. The resident's medical records indicated she was alert, oriented, and had moderate cognitive impairment, with a stated preference for communication in Cantonese and a need for an interpreter. During interviews, the resident reported having to wait for family members to communicate her needs, as staff did not use available translation resources. Staff members, including an LVN and CNA, were unable to locate a communication board in the resident's room and demonstrated a lack of knowledge regarding the use of language line services. The Director of Staff Development also failed to show that communication aids were available for the resident. Family members expressed concern about the resident's ability to have her needs met, especially during times when family was not present. They confirmed that staff had not used communication boards or translation services during the resident's stay. The facility's failure to provide these accommodations had the potential to negatively impact the resident's psychosocial well-being and could result in delayed provision of care, as the resident's needs may not have been effectively communicated or addressed.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who was prescribed an anticoagulant medication, apixaban, for atrial fibrillation. The resident was admitted with a physician's order for apixaban, and the medical record confirmed the resident had the capacity to understand and make decisions. Despite this, a review of the resident's medical record did not show any care plan addressing the use of the anticoagulant medication. Interviews with facility staff, including an RN, LVN, the Medical Records Director (MRD), the MDS Coordinator, and the Director of Nursing (DON), confirmed that no care plan was developed for the anticoagulant medication. The RN verified the existence of the physician's order but stated she was not responsible for developing care plans for anticoagulant use upon admission. The LVN emphasized the importance of having a care plan for anticoagulant medications to outline goals and interventions such as monitoring for side effects and reassessment of outcomes. Further interviews revealed that the MRD was responsible for auditing new admission charts for medication entries and baseline assessments, but the ADON and MDS Coordinator were responsible for reviewing and initiating care plans for medications. The MDS Coordinator confirmed that a care plan for anticoagulant use should have been initiated as soon as possible and acknowledged its absence in the resident's record. The DON was informed and acknowledged the findings.
Failure to Repair Cracked Floor Creates Safety Hazard
Penalty
Summary
The facility failed to maintain the flooring in a safe and good repair, as evidenced by the presence of a cracked floor in the hallway from the entrance to nurse station 1, in front of the rehab service room and patio. Multiple residents, including those with mobility impairments and fall risks, were observed traversing this area. The cracked floor was directly observed by surveyors, and residents as well as staff acknowledged its unsafe condition, noting the potential for falls. Resident records reviewed showed that affected individuals had significant medical histories, including diabetes, COPD, osteoarthritis, cerebral infarction, hypertension, paraplegia, and rheumatoid arthritis. These residents required varying levels of assistance with mobility and activities of daily living, and their care plans specifically called for a safe, clutter-free environment to prevent falls. Despite these documented needs, the cracked floor remained unaddressed. Interviews with residents, a Licensed Vocational Nurse, the Maintenance Director, and the administrator confirmed that the cracked floor had not been reported or repaired. The Maintenance Log contained no entries regarding the issue, and no warning signs had been placed to alert residents or staff. The facility's own maintenance policy required regular upkeep of flooring to prevent injuries, but this was not followed in this instance.
Plan Of Correction
General Maintenance How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 10/09/25, the Maintenance Supervisor (MS) repaired the crack on the hallway floor near Station 1 and the Rehabilitation Room to eliminate any potential safety hazard for residents. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 10/21/25, the Safety Committee conducted a comprehensive walk through of the facility to identify any additional cracks or floor hazards throughout all resident and common areas. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/21/25 and 10/22/25, the Director of Staff Development (DSD) and Maintenance Supervisor (MS) provided in-service training to all staff regarding the use and importance of the Maintenance Log for timely reporting and follow-up on facility repairs. - Beginning 10/22/25, the Maintenance Supervisor will conduct floor inspections 2-3 times per week for three months to monitor for cracks or hazards and ensure prompt corrective action is taken as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Maintenance Supervisor (MS) will be reporting the results of the monitoring to the QA committee and safety committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Notify Physician of Resident's Sudden Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a sudden and marked change in a patient's behavior, as required by regulation. Patient 4, who had diagnoses of hypertension and congestive heart failure and was cognitively intact, refused a shower and began screaming when staff attempted to change her soiled incontinence briefs. The situation escalated to the point where the patient was yelling, laughing inappropriately, and ultimately kicked a staff member. Multiple staff, including the Administrator and Director of Social Services, were present and attempted to address the situation, but the physician was not notified of this significant behavioral change. Interviews with staff, including the CNA, Administrator, Director of Staff Development, LVN, and Director of Nursing, confirmed that the physician should have been informed of the change in the patient's condition. The facility's own policy also required prompt notification of the physician and resident representative in the event of a change in the resident's medical or mental condition. The failure to report this incident represented a lapse in following both regulatory and facility policy requirements.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/7/2025, the RN supervisor assessed Patient 4 for any signs of adverse outcome regarding refusals to showers/bed bath. Upon explanation and discussing the importance of showers, Patient 4 was still not convinced to allow the CNA to continue with the hygienic and care procedure. CNA was relieved from her care and another CNA was assigned immediately with no further issues. Change of Condition was initiated and completed by the Charge Nurse to reflect Patient 4's behavior. MD and responsible party (RP) were made aware of patient 4's refusals. Patient 4's care plan was updated by the MDS nurse to signify her behavior change. Patient 4 will be monitored for 72-hours for any other changes. On 10/7/2025, the Director of Nursing Services (DON) and Director of Staff Development (DSD) completed an in-service to nursing staff on how to handle patient refusals of showers and notification requirements and processes for changes of condition. A policy and procedure titled, "CHANGE of CONDITION," was reviewed and discussed followed by question-and-answer evaluation. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, DSD interviewed all CNAs on shift to identify additional patients with episodes of care needs refusals, included them on a "Special Care Needs" list to ensure proper monitoring and appropriate interventions as individualized as possible. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025, DON held an in-service with all licensed nurses on P/P: Change of Condition, with an emphasis on MD/RP notification. On 10/29/2025, two additional systematic changes were implemented: 1. "Resident Special Care Needs" worksheet was modified to include patients with episodes of refusals of care needs. The list will be generally updated weekly and as changes occur by the Desk Nurse, to be shared on both nursing units. 2. "Huddle" every shift to review patients with special needs such as giving detailed attention to the patients who would tend to refuse care. Discussed with the team huddle the importance of reporting any incident of refusals to immediately implement interventions as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Weekly audits on refusals based on Change of Condition reports will be reviewed by the DON/Designee. The DON/Designee will present any findings to the QAPI/QAA Committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900
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