Cottage Crest Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 12350 Rosecrans, Norwalk, California 90650
- CMS Provider Number
- 055758
- Inspections on file
- 43
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cottage Crest Post Acute during CMS and state inspections, most recent first.
A resident with dementia and documented lack of decision-making capacity underwent a tooth extraction after a dentist, assisted by an LVN acting as translator, obtained the resident’s signature on a dental consent form without verifying capacity or contacting the Responsible Party (RP). The attending physician had cleared the resident for possible extractions and directed the dentist to call the RP, but no call or consent from the RP was obtained. The RN supervisor declined to witness the consent post‑procedure because he knew the resident lacked capacity and that the family made healthcare decisions. The RP later reported not being informed of the dental problem or the extraction, despite facility policies and a dental services agreement requiring that resident representatives be informed and valid informed consent be obtained before treatment.
A resident with dementia, metabolic encephalopathy, impaired decision-making, incontinence, and need for assistance with ADLs had an existing fall-risk care plan identifying risks related to incontinence, psychoactive medications, and poor safety awareness, with interventions focused on environmental safety and staff responsiveness. The resident sustained an unwitnessed fall, was found on the floor with a bleeding forehead laceration, and was transferred to a hospital by paramedics. After the fall, there was no documented IDT care conference with the resident’s representative, and the fall-risk care plan was not revised to include new or modified interventions, despite RN, DOR, and DON acknowledgments that licensed nurses and the IDT are responsible for updating care plans and facility policies requiring care plan review and revision following such events.
A resident with depression, intact decision-making capacity, and documented preferences for outdoor patio activities, outings, and shopping was not provided with these preferred activities despite care plan interventions directing staff to offer meaningful, individualized activities. Activity assessments repeatedly identified the resident’s interest in going outside and into the community, but review of several months of activity calendars showed no outings or shopping opportunities. The resident reported feeling sad and frustrated about being confined indoors and expressed a desire to leave the facility to shop and feel more normal. Staff interviews confirmed that the facility primarily offered indoor activities and had not arranged group outings, with the Activity Director citing transportation permit issues while acknowledging that residents’ choices, including outings and shopping, should have been honored.
A resident with dementia, metabolic encephalopathy, and mobility difficulties experienced an unwitnessed fall resulting in facial bleeding and a forehead laceration, was found on the floor near the nurses’ station, and was transferred to a GACH via 911. Although an RN reported assessing and monitoring the resident’s vital signs during this change of condition, there was no documentation of vital signs in the Change of Condition Evaluation or progress notes. The DON confirmed that nursing staff are responsible for complete records and that assessments, including vital signs, should be documented at the time of service, consistent with facility policy requiring accurate, relevant, and complete medical record documentation.
Surveyors found that the facility did not develop or implement comprehensive, person-centered care plans for four residents, including missing care plans for anticoagulant monitoring, bowel and bladder retraining, and hypoglycemia management, despite documented needs and significant clinical events.
Three residents who were incontinent of bowel and bladder did not receive required assessments or retraining programs to restore or maintain continence. Assessments were incomplete or not conducted as required, and care plans and physician orders lacked interventions for bowel and bladder retraining, despite facility policy and staff acknowledgment that such programs were necessary.
Surveyors found that food items were not consistently dated, labeled, or discarded according to policy, and that a cook failed to perform proper hand hygiene and glove changes between tasks during meal service. These deficiencies in food storage and handling practices affected nearly all residents and were not in compliance with facility policies.
A COVID-19 outbreak involving several residents with various medical conditions was not reported to the State Agency as required. The IPN reported the outbreak to the local public health agency and the CDC's NHSN, but did not notify the State Agency, believing local reporting was sufficient. The DON was unaware of the direct reporting requirement until reviewing state guidance. This failure was identified through interviews and record review.
The facility did not follow its antibiotic stewardship protocols for two residents who were prescribed antibiotics without meeting McGeer’s criteria for infection. Required documentation and physician notification were not completed, and the infection preventionist nurse was unaware of one resident’s antibiotic use. The facility’s policy mandates use of McGeer criteria and timely review of antibiotic use, but these steps were not followed.
A resident with depression and multiple cardiac conditions was prescribed Celexa, an antidepressant, without documented informed consent. The resident was cognitively intact, and facility policy required that residents be informed of the risks and benefits of psychotropic medications prior to initiation, but this was not done or documented.
A resident with diabetes and dementia did not receive proper care after insulin administration, as staff failed to ensure meal consumption, did not monitor blood glucose after a missed meal, and delayed checking blood sugar when the resident became unresponsive. There was no care plan or standing order for hypoglycemia treatment, and the resident required hospitalization due to these failures.
A resident with a history of atrial fibrillation, CAD, and CHF was prescribed Apixaban, but the facility did not develop a comprehensive, person-centered care plan for anticoagulant monitoring. The care plan lacked details on monitoring for side effects, and staff confirmed that the resident was not being monitored for adverse effects as required.
A tube of Triamcinolone Acetonide cream used for a resident with diabetes and cognitive impairment was found in a medication cart without a label or date. The DON confirmed the medication should have been labeled and dated according to facility policy, which requires resident and medication information on all drug containers.
The facility did not meet federal requirements for minimum bedroom size, with 33 multi-resident rooms and two single-resident rooms measuring below the required square footage per resident. Despite awareness of the deficiency by facility leadership and the presence of an approved room waiver, observations showed residents had enough space for movement and use of mobility aids, and no complaints were reported by residents or staff.
The facility did not provide documentation that its 50-year-old sprinkler system met required testing or replacement standards, with inspection reports showing failed tests and overdue maintenance. Additionally, an electrical outlet at a nurse station was found with a broken faceplate, exposing metal terminals, and the issue had not been previously identified by facility staff.
Surveyors observed that the fire alarm system's circuit disconnecting means was not identified with a red marking as required by NFPA codes. The Maintenance Supervisor acknowledged the deficiency, and a review of the facility's preventative maintenance policy confirmed the expectation for compliance.
An electrical outlet at Nurse Station #2 was found with a broken faceplate, exposing metal terminals. The CMO confirmed the damage had not been previously noticed. Facility policy assigns the Maintenance Director responsibility for maintaining safe equipment, but the exposed outlet was not addressed as required by NFPA 70.
A full H-sized oxygen cylinder was stored in the beauty salon without the required 'No Smoking' signage, as observed by surveyors. The CMO confirmed the absence of the sign and the use of the salon for temporary storage. Facility policy requires precautionary signs to be posted where oxygen is stored, but this was not followed, resulting in noncompliance with NFPA 99 standards.
A resident with cognitive and mobility impairments was unable to reach their call light and telephone, leading to frustration and potential delays in care. Staff interviews confirmed the importance of keeping these items accessible, as outlined in the facility's policies, but the failure to do so resulted in the resident's distress and risk of injury.
A resident with a history of osteoporosis and dementia sustained an acute right femoral neck fracture and right temporal hematoma of unknown cause. The facility failed to report this unusual occurrence to CDPH within the required 24-hour timeframe, delaying an onsite inspection. Despite severe pain and visible injuries, the facility's DON and Administrator waited for hospital confirmation before reporting, contrary to policy requirements.
A resident with cognitive impairment and multiple health conditions experienced verbal abuse by a CNA, who made a hurtful comment about the resident's smell, causing significant emotional distress. The incident was reported by an LVN, and staff interviews confirmed the comment was considered verbal abuse according to facility policy.
A facility failed to create a person-centered care plan for a resident with diabetes, risking episodes of hypoglycemia or hyperglycemia. The care plan was delayed by 16 days and lacked details on medication and blood sugar monitoring frequency. The DSD confirmed these omissions, which violated the facility's policy for comprehensive care plans.
A resident with type 2 diabetes and a history of hypoglycemia was admitted to an LTC facility without an order for routine blood sugar monitoring, despite being on insulin. This oversight led to a hypoglycemic episode, highlighting a deficiency in following up with the physician for necessary monitoring orders.
A long-term care facility experienced a medication error rate of 48.78%, affecting all observed residents. Errors included omitted doses, incorrect administration techniques, and failure to follow physician-ordered parameters. Residents missed critical medications for hypertension, heart function, and infection, placing them at risk for serious complications.
The facility failed to provide adequate RNA staff, resulting in 28 residents not receiving necessary restorative services. CNA direct care hours fell below the required minimum, and the facility did not use contracted registry staff to address the shortage. Interviews revealed that RNAs were often pulled to work as CNAs, and the Administrator was unaware of the staffing issues.
The facility failed to ensure LVNs were properly trained to administer medications via g-tube according to physician's orders, affecting three residents. One LVN used a push method instead of gravity, another prepared to administer medications without specific orders, and a third did not verify updated orders before administration. These actions could lead to cross-contamination and increased infection risk.
The facility failed to ensure the availability of critical medications for five residents, including metoprolol tartrate and apixaban, and did not maintain accurate medication administration records for two residents. This led to potential health risks due to untreated conditions and inaccurate documentation.
The facility failed to maintain safe food storage and hygiene practices, with expired and improperly stored food items found in the kitchen. Raw meats were stored alongside other foods, risking cross-contamination. Staff did not follow hand hygiene protocols, increasing the risk of bacterial spread.
The facility failed to properly cover two large dumpsters and two smaller carts, leading to potential cross-contamination risks for 54 residents. During an observation, the Dietary Manager noted that the dumpsters were overflowing and could not be closed, and acknowledged that the bins should be sealed to prevent infestations. The facility's policy and the Food Code 2017 require that such receptacles be covered when not in use.
The facility failed to address unresolved deficiencies in staffing and medication management, leading to insufficient CNA hours and a high medication error rate. Two RNAs were unavailable, affecting 28 residents, and medications were not in stock for five residents. The Administrator was unaware of these issues until the Immediate Jeopardy process, and the QAPI committee meetings did not effectively resolve them.
The facility failed to offer and document advance directives for two residents. One resident had an incomplete directive lacking required signatures, while another was not offered an advance directive upon admission or quarterly. Interviews with the Social Services Director and DON confirmed these deficiencies, which were contrary to the facility's policy.
A facility failed to accurately document a resident's nutritional status on the MDS, incorrectly indicating parenteral and enteral nutrition. Additionally, another resident's fall risk assessments were inconsistent with therapy evaluations, failing to reflect the true fall risk. These documentation errors could impact the residents' care plans and service delivery.
The facility failed to ensure proper use and monitoring of psychotropic medications for several residents, leading to unnecessary drug administration and potential adverse effects. One resident received increased doses of Seroquel without documented necessity, and another was given Ativan and Sertraline without proper documentation of anxiety and depression episodes. Additionally, a resident continued to receive Seroquel after it was ordered to be discontinued, resulting in hospitalization due to adverse effects. The facility did not adhere to policies regarding informed consent and monitoring for adverse effects.
Two residents in an LTC facility experienced significant medication errors due to unavailable medications and failure to follow protocols. One resident did not receive metoprolol tartrate due to it being out of stock, while another missed doses of potassium chloride and apixaban. The LVN involved did not notify the pharmacy or physician about the shortages, and the DON acknowledged the need for timely medication administration and reordering.
The facility failed to implement proper infection control measures, including hand hygiene and PPE use, during resident care and medication administration. A CNA did not perform hand hygiene, and another did not wear PPE for a resident on enhanced precautions, risking cross-contamination. An LVN failed to disinfect medication trays and perform hand hygiene, compromising infection control.
A resident with chronic health issues was transferred to the hospital without a documented significant change of condition (COC) by the facility. Despite the facility's policy requiring notification of the resident's physician and next-of-kin, staff interviews revealed that no COC was completed, potentially leaving the resident's condition unmonitored.
The facility failed to accurately complete PASARR evaluations for several residents with serious mental illnesses and developmental disabilities. This deficiency involved incorrect or incomplete assessments, leading to potential risks in providing necessary care. The DON acknowledged the oversight, emphasizing the importance of accurate PASARR assessments.
The facility failed to develop timely baseline care plans for two residents, one with a history of falls and psychotropic medication use, and another with a history of seizures. The care plans were not initiated within the required timeframe, leaving gaps in the management of their conditions. Interviews with staff highlighted that the facility's policies on care plans were not followed, resulting in deficiencies in care.
A resident with multiple medical conditions and high fall risk experienced six falls due to the facility's failure to implement person-centered interventions and revise the fall risk care plan. The facility did not conduct proper post-fall assessments or neurological checks, and interventions were inconsistently applied. Despite being on psychotropic medication, the potential risk factors were not addressed, leading to inadequate fall prevention measures.
A resident with multiple medical conditions and high risk for pneumonia did not receive the pneumonia vaccine despite physician orders. The resident was dependent on nursing staff and lacked decision-making capacity. The absence of vaccine administration documentation led to the resident developing pneumonia twice, requiring hospital transfers.
The facility failed to meet the required space of 80 square feet per resident in multi-bed rooms and 100 square feet for single rooms, with 33 rooms falling short of these standards. Despite this, observations indicated that residents had enough space to move freely, and the room size did not affect the nursing care or privacy provided. The Administrator was aware of the requirements and had previously approved a room waiver.
Tooth Extraction Performed Without Responsible Party Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Responsible Party (RP) was informed of the resident’s dental needs and that valid consent was obtained prior to a tooth extraction, despite the resident lacking decision-making capacity. The resident had diagnoses of metabolic encephalopathy and dementia, and the Minimum Data Set and History and Physical documented that the resident was not able to make reasonable and consistent decisions and did not have capacity to understand and make decisions. The resident required assistance with activities of daily living. A Dental Medical Order form proposed extraction of teeth numbers 12 and 29, and the attending physician signed this form to provide medical clearance, with instructions for the dentist to call the RP to explain the procedure. On the day of the procedure, the dentist proceeded with the extraction of tooth number 12 after explaining the procedure to the resident through LVN 1, who acted as a translator. The dentist obtained the resident’s signature on a Dental Procedure Consent form, which stated that the resident had read the consent and had questions answered to her satisfaction, and LVN 1 signed as a witness to the resident’s consent. The dental progress note documented that tooth number 12 was unrestorable and was extracted using forceps with local anesthetic, while tooth number 29 was not extracted. A Change of Condition evaluation recorded that the resident underwent extraction of tooth number 12. No documentation showed that the RP was contacted or that consent was obtained from the RP before the procedure. After the extraction, the RP complained that the tooth had been removed without her knowledge or consent and stated she had not been informed of the resident’s dental concerns or need for extraction by the dentist or nursing staff. LVN 1 acknowledged that she did not call the RP or check the medical record to verify the resident’s capacity or the need for RP consent, assuming this had already been done. The Registered Nurse Supervisor reported that he declined to witness the consent after the procedure because he knew the resident lacked capacity and that the family was responsible for healthcare decisions. The dentist stated he did not call the RP, assumed the dental office had contacted the family, did not verify the resident’s cognition or capacity, and noted that the face sheet did not indicate a designated RP. Facility policies on notification of changes, informed consent, resident rights, and dental services required that resident representatives be informed and involved in decisions and that informed consent be verified prior to treatment, and the Dental Facilities Services Agreement required the dentist to maintain legal informed consent signed by residents and/or their responsible parties.
Failure to Revise Fall-Risk Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s fall-risk care plan after a documented fall. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and difficulty walking. An MDS assessment dated 7/8/2025 showed the resident was unable to make reasonable and consistent decisions, required partial to moderate assistance with ADLs such as transfers and repositioning, and was incontinent of bowel and bladder. A care plan dated 8/10/2025 identified the resident as at risk for falls due to incontinence, psychoactive drug use, and unawareness of safety needs, with goals for the resident to be free from falls and serious injury. Interventions included anticipating and meeting needs, prompt staff response to calls, and maintaining a safe environment with clear pathways, adequate lighting, and personal items and call light within reach. On 12/25/2025, a Change of Condition Evaluation documented that the resident had a fall and was found sitting on the lobby floor with blood on her face. A Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized, actively bleeding cut on the forehead. Paramedics were called, and the resident was transferred to a general acute care hospital via 911 for further treatment. The resident’s emergency contact later stated that staff informed her of the fall incident but did not call her to attend a meeting to discuss care concerns and interventions after the fall. Record review showed no documentation that the IDT implemented a care conference with the resident’s emergency contact to discuss recommendations, changes, or updates to the fall-risk care plan after the fall. The resident’s fall-risk care plan contained no revisions or updates to include interventions following the 12/25/2025 fall. RN 1 stated that the resident had an unwitnessed fall at change of shift, that he instructed the CNA to perform frequent visual checks, and that he was unable to review and revise the fall-risk care plan or formulate a care plan for an actual fall, acknowledging that licensed nurses are responsible for updating and revising care plans. The Director of Rehab and the DON both confirmed that there was no documented IDT meeting and that the resident’s fall-risk care plan was not revised or updated after the fall, despite facility policies requiring development, implementation, and revision of comprehensive care plans and review and updating of care plans under the fall prevention program.
Failure to Provide Resident With Preferred Outings and Shopping Activities
Penalty
Summary
The facility failed to provide a resident with preferred activities, specifically outdoor patio activities, outings, and shopping, as identified in the resident’s activity assessments and care plan. The resident, who had a diagnosis of depression and the capacity to understand and make decisions, was assessed on multiple occasions as enjoying outdoor and community-based activities. The Minimum Data Set indicated the resident could make reasonable and consistent decisions, required partial to moderate assistance with ADLs, and used a manual wheelchair for mobility. The resident’s care plan for depression included interventions to assist him in developing and providing meaningful activities of interest, with a goal of being free from signs and symptoms of distress and not exhibiting indicators of depression such as a sad mood or anxiety. Despite these documented preferences and care plan interventions, review of the facility’s activity calendars over several months showed no outings or shopping activities offered. In interviews, the resident reported wanting to leave the facility on good-weather days to purchase items from a store and stated that remaining inside made him feel sad and frustrated, expressing a desire to do something outside or away from the facility to feel like a normal human being. A restorative nursing assistant confirmed that the resident had expressed a wish to go shopping and that the facility mostly provided indoor activities rather than outings. The Activity Director acknowledged that no group outings had been provided, citing the need to apply for a government ride permit for each resident, and stated that residents’ activities of choice should have been planned and implemented, including outings and shopping when families were not available to take residents out. The DON and Administrator both stated that the resident’s activity interests should have been provided to promote meaningful experiences and ensure comfort and quality of life.
Failure to Document Vital Signs After Resident Fall and Change of Condition
Penalty
Summary
The facility failed to ensure accurate documentation of vital signs during a resident’s change of condition following a fall. Resident 2, who had diagnoses including metabolic encephalopathy, dementia, and difficulty walking, and who required partial to moderate assistance with ADLs and was incontinent of bowel and bladder, experienced an unwitnessed fall. A Change of Condition Evaluation dated 12/25/2025 documented that the resident was found sitting on the lobby floor with blood on her face, but there was no documentation of vital signs at that time. A subsequent Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized cut on the forehead that was actively bleeding and that paramedics were called and the resident was transferred to a general acute care hospital via 911, again with no vital signs documented in the clinical record during this change of condition. In a telephone interview, RN 1 stated that the resident had an unwitnessed fall at change of shift and that he was able to assess and monitor the resident’s vital signs during the change of condition but did not document those vital signs in the clinical record. RN 1 acknowledged that he should have documented the vital signs to depict the resident’s accurate well-being after the fall. In an interview, the DON stated that RN 1 should have documented the assessments and monitoring during the change of condition, including current vital signs, to reflect the resident’s accurate well-being after the fall and to determine her condition and/or deterioration, and affirmed that it was the responsibility of nursing staff to ensure residents’ records are complete. The facility’s policy on Documentation in Medical Record required that medical records contain enough information to provide a picture of the resident’s progress and that nursing staff document accurate, relevant, and complete assessments and observations at the time of service, which was not followed in this instance.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, as required by federal regulations. For one resident with a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, the care plan did not adequately address the use of Apixaban, an anticoagulant. The Quality Assurance Nurse confirmed that the care plan lacked information on monitoring for side effects, such as bleeding, which is essential for residents on blood thinners. Two other residents, both with histories of urinary retention and neurological or muscular conditions, were identified as candidates for bowel and bladder retraining based on their assessments. Despite documented frequent incontinence and assessment scores indicating suitability for retraining programs, there were no care plans initiated or updated to address bowel incontinence or retraining for these residents. The Registered Nurse Supervisor acknowledged that the absence of these care plans could delay necessary treatment and that all concerns should be reflected in the care plan. Another resident with diabetes mellitus and dementia experienced a significant hypoglycemic event, as documented in the nurse's progress notes. Despite this event, there was no care plan developed to address hypoglycemia. The Director of Nursing confirmed that care plans should be specific and interventions should be implemented and reevaluated, especially following significant events. The facility's own policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in these cases.
Plan Of Correction
F656 - Develop/Implement Comprehensive Care Plan • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) added the monitoring of the side effect for Apixaban, which included monitoring bleeding for Resident 45. (Exhibit #5) - On 5/29/25, the Registered Nurse Supervisor 1 (RNS1) added bowel incontinence and bowel and bladder retraining in the care plan for Resident 10 and Resident 44. (Exhibit #6) - On 5/30/25, the Director of Nursing (DON) included hypoglycemia monitoring in the care plan for Resident 23. (Exhibit #7) • 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 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents with anticoagulants, possible candidates for bowel and bladder retraining, and residents at risk for hypoglycemia to ensure care plans were completed accurately. (Exhibit #8) - No other residents were affected by the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #9) - Starting on 6/17/25, the DON and QAN will conduct a weekly review for three months to ensure care plans were developed and implemented, particularly for anticoagulant medications, hypoglycemia, and bowel and bladder assessment and training programs. (Exhibit #10) - Starting on 6/17/25, the DON will report to the administrator any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON will discuss any trends or patterns during the monthly QA committee meetings for three months for review and recommendations and will re-evaluate if any further concerns are identified afterward. Date of completion: June 20, 2025
Failure to Provide Bowel and Bladder Retraining for Incontinent Residents
Penalty
Summary
The facility failed to ensure that three residents who were incontinent of bowel and bladder received appropriate assessments and retraining programs to restore or maintain continence, as required by federal regulations. For one resident, the bowel and bladder assessment was not completed quarterly, and although an initial assessment indicated the resident was a candidate for retraining, there was no evidence of a retraining program being implemented. The resident's care plan and physician orders did not include any interventions for bowel and bladder retraining, and the most recent assessment was incomplete. Another resident did not have a bowel and bladder assessment conducted upon admission, and there was no evidence that the resident participated in a retraining program. The resident's condition changed from frequent incontinence to always incontinent, but no new assessment or retraining program was initiated. The care plan and physician orders for this resident also lacked any mention of bowel and bladder retraining interventions. A third resident was identified as a candidate for prompt toileting based on a completed assessment, but subsequent assessments were incomplete, and the resident was not placed in a bowel and bladder training program. Staff interviews confirmed that the resident should have been included in such a program, and the facility's policy required individualized, resident-centered restorative toileting programs to be care planned and reevaluated at least quarterly. Despite this, there was no evidence that the required assessments and interventions were consistently implemented for these residents.
Plan Of Correction
F690 - Bowel/Bladder Incontinence, Catheter, UTI How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/16/25, the Director of Nursing (DON) conducted a bowel and bladder assessment for Resident 3, 10, and 44. The respective residents were offered bowel and bladder training. (Exhibit #16) 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 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the bowel and bladder assessments of the residents. The bowel and bladder training were offered to those residents that qualified for the bowel and bladder program. (Exhibit #17) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Bladder and Bowel Incontinence: A Care Solution," Copyright 2022. (Exhibit #18) - Beginning on 6/17/25, the Minimum Data Set Director (MDSD) will review the bowel and bladder assessment of the residents weekly for three months to identify those residents who are good candidates for bowel and bladder training program. The MDSD will include those residents who are newly admitted to the facility. (Exhibit #19) - Starting on 6/17/25, the MDSD will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The MDSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Deficient Food Storage, Labeling, and Hand Hygiene Practices
Penalty
Summary
Surveyors identified deficiencies in the facility's food storage and handling practices, which affected 47 out of 50 residents. During observations in the dry storage area, several food items were found not properly dated, labeled, sealed, or discarded. Examples included opened sundried tomatoes without an open date, fresh yams with damaged and exposed surfaces, and opened muffin mix lacking required dates. In the refrigerator, opened pasteurized eggs and snap peas were also missing appropriate use-by dates. The Dietary Supervisor confirmed that all dietary staff, including herself, were responsible for ensuring food items were labeled, dated, and stored according to facility policy, which was not consistently followed. Further review of facility policies revealed that opened food items should be marked with receiving, open, and use-by dates, and that staff should refer to storage charts for appropriate shelf life. The policies also required that expired or outdated food products be discarded and that all products be inspected for safety and quality. Despite these policies, the survey found multiple instances where food items were not managed according to these standards, increasing the risk of foodborne illness among residents. Additionally, during meal service, a cook was observed failing to perform proper hand hygiene and glove changes between tasks. After handling a lunch cart and touching a doorknob, the cook did not wash hands or change gloves before handling another resident's tray, which she acknowledged was not in line with infection control practices. The Director of Nursing confirmed that all staff should perform hand hygiene between tasks to prevent cross-contamination. Facility policies reviewed by surveyors also emphasized the importance of hand hygiene and safe food handling, but these were not adhered to during the observed meal service.
Plan Of Correction
F812 - Food Procurement, Store/Prepare/Serve- Sanitary • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/27/25, the Dietary Supervisor (DS) removed and discarded the food items identified without label and exceeded the used by dates. - On 5/27/25, the DS called the attention of cook 2 (CK2) to perform hand hygiene and change gloves in between tasks. • 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: - Not applicable. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 5/28/25, the Infection Prevention Nurse (IPN)/DS provided one-on-one in-service to CK2 regarding the facility policy and procedure entitled, "Food Safety and Food Storage," revised 11/4/2024, and "Hand Hygiene," revised 12/19/2022. (Exhibit #35) - On 5/28/25, the DS provided in-service to the active kitchen staff regarding the policy and procedure entitled, "Dry Storage Chart," dated 2023; "Refrigerated Storage Chart," dated 2020; "Date Marking for Food Safety," revised 12/19/2022; and "Food Storage," revised 8/29/2023. (Exhibit #36) - Beginning on 6/17/25, the DS will conduct observations weekly for three months to ensure food items are stored and labeled accordingly. In addition, the DS will observe the kitchen staff perform hand hygiene and change gloves in between tasks. (Exhibit #37) - Starting on 6/17/25, the DS will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - On 5/28/25, the Infection Prevention Nurse (IPN)/DS provided one-on-one in-service to CK2 regarding the facility policy and procedure entitled, "Food Safety and Food Storage," revised 11/4/2024, and "Hand Hygiene," revised 12/19/2022. (Exhibit #35) - On 5/28/25, the DS provided in-service to the active kitchen staff regarding the policy and procedure entitled, "Dry Storage Chart," dated 2023; "Refrigerated Storage Chart," dated 2020; "Date Marking for Food Safety," revised 12/19/2022; and "Food Storage," revised 8/29/2023. (Exhibit #36) - Beginning on 6/17/25, the DS will conduct weekly observations for three months to ensure proper food storage and labeling, as well as hand hygiene and glove-changing practices. (Exhibit #37) - The DS will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified afterward. Date of completion: June 20, 2025.
Failure to Report COVID-19 Outbreak to State Agency
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the State Agency as required by federal and state regulations. Multiple residents tested positive for COVID-19 over a period of time, with laboratory results confirming positive cases for six residents. The infection prevention nurse (IPN) acknowledged that the outbreak began when three residents tested positive and reported the incident to the local public health agency and the CDC's National Healthcare Safety Network, but did not notify the State Agency. The IPN believed that reporting to the local agency would automatically result in notification to the State Agency. Further review revealed that the Director of Nursing (DON) was not aware that the State Agency required direct notification and only realized this after reviewing the relevant All Facilities Letter (AFL 23-08), which clarified the reporting requirements. The facility's own policy and procedure on infection outbreak response indicated that outbreaks should be reported to local and/or state health departments in accordance with state requirements, but this was not followed in practice. The residents involved had various medical conditions, including pneumonia, prostate cancer, atrial fibrillation, coronary artery disease, congestive heart failure, stage 4 kidney disease, lupus, hypertension, colon cancer, bronchitis, morbid obesity, and hyponatremia. Some residents had moderate cognitive impairment, while others were cognitively intact. The failure to report the outbreak to the State Agency was identified through observation, interviews, and record review, and was considered a deficiency in the facility's infection prevention and control program.
Plan Of Correction
F880 - Infection Control Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Infection Prevention Nurse (IPN) initiated the reporting of COVID-19 outbreak to California Department of Public Health (CDPH). Exhibit #27 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: - Not applicable What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Infection Outbreak Response and Investigation," dated 12/19/2022. (Exhibit #28) - Starting on 6/2/25, the IPN will review the number of cases daily until the outbreak is over and report to CDPH accordingly. - Beginning on 6/2/25, the IPN will report to the CDPH the COVID-19 outbreak. - On 6/13/25, the IPN received Respiratory Illness Outbreak clearance letter. (Exhibit #29) How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. - Date of completion: June 20, 2025
Failure to Follow Antibiotic Stewardship Protocols for Two Residents
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program policy and procedure for two residents who were prescribed antibiotics without meeting the established criteria. One resident, admitted with type 2 diabetes, a foot ulcer, osteomyelitis, and a right foot amputation, was prescribed intravenous Piperacillin Sod-Tazobactam. Review of the resident's Infection Screening Evaluation indicated that the symptoms did not meet McGeer’s criteria for infection, and the Antibiotic Time Out form did not show that the physician was notified of this. Another resident, admitted with acute kidney failure and a urinary tract infection, was prescribed oral Ciprofloxacin. The Infection Screening Evaluation for this resident also indicated that McGeer’s criteria were not met, and the Antibiotic Time Out was not completed within the required timeframe. Interviews with the infection preventionist nurse revealed a lack of awareness regarding the antibiotic use for one resident and a failure to complete the required Antibiotic Time Out documentation. The infection preventionist nurse confirmed that the physician should be notified when criteria are not met and that this communication should be documented, but this was not done in either case. The facility’s policy states that McGeer criteria are used to define infections and that education on the antibiotic stewardship program should be provided to staff, practitioners, residents, and families, but these procedures were not followed for the two residents involved.
Plan Of Correction
F881 - Antibiotic Stewardship Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Infection Prevention Nurse (IPN) reviewed the antibiotic stewardship for Resident 43 and 154 and notified the MD. (Exhibit #30) 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 6/2/25, the IPN reviewed the list of residents on antibiotics, checked if the residents met McGeer's criteria, and if the physician was notified for the antibiotic time out. (Exhibit #31) - No other resident was affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #32) - Starting on 6/17/25, the IPN provided in-service to the active licensed nurses regarding the policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #33) - Beginning on 6/17/25, the DON will review the Antibiotic Stewardship Program weekly for three months to ensure the physicians were notified if there is an antibiotic time out. (Exhibit #34) - Starting on 6/17/25, the IPN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to obtain informed consent for the administration of Celexa, an antidepressant medication, to a resident diagnosed with depression. The resident, who was cognitively intact and had a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, was admitted to the facility and subsequently prescribed Celexa for depression manifested by low interest and motivation with activities of daily living. Review of the resident's records confirmed that informed consent was not documented prior to starting the medication. During an interview, the Quality Assurance Nurse acknowledged that informed consent had not been obtained before initiating the psychotropic medication, despite facility policy requiring that residents, families, or representatives be informed of the risks and benefits of such medications and that this information be documented in the resident's chart. The facility's policy specifically included antidepressants as psychotropic medications for which informed consent is required.
Plan Of Correction
F552 - Right to be informed/ Make Treatment Decisions How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/30/25, the Quality Assurance Nurse (QAN) offered and secured the consent from Resident 45 regarding the Celexa medication. (Exhibit #1) 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 6/2/25, the Social Service Director (SSD) and QAN reviewed the list of residents with psychoactive medications orders to ensure that informed consents were signed and obtained. (Exhibit #2) - No other resident was affected of the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the licensed nurses regarding the facility's policy and procedure (P&P) titled "Use of Psychotropic Medications" dated 3/17/2025. (Exhibit #3) - Starting on 6/16/25, the SSD will conduct a weekly review for three months of the informed consents for those residents who will be receiving psychoactive medications orders. In addition, the SSD will review the informed consents of the newly admitted residents. (Exhibit #4) - Starting on 6/16/25, the SSD will report to the administrator any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The SSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Failure to Provide Appropriate Hypoglycemia Management
Penalty
Summary
A deficiency occurred when a resident with diabetes and dementia, who required significant assistance with activities of daily living, did not receive appropriate care for a hypoglycemic episode. The resident was administered eight units of insulin after a high blood glucose reading, but subsequently consumed none of their dinner. Staff failed to ensure the resident ate after receiving insulin, which is necessary to prevent hypoglycemia, and did not monitor the resident's blood glucose levels following the meal refusal. Later that evening, the resident was found unresponsive. Staff checked vital signs but did not immediately check the resident's blood glucose level to rule out hypoglycemia. The blood glucose was not measured until paramedics arrived, at which point it was found to be critically low (40 mg/dl). There was no evidence that staff provided timely treatment for hypoglycemia, such as administering Glucagon or other interventions, nor did they consult the primary physician promptly for emergency orders. Record review revealed that the resident did not have a care plan addressing hypoglycemia, and there were no standing orders for Glucagon or other hypoglycemia treatments. Facility policies required glucose monitoring and treatment protocols for residents at risk, but these were not followed. The failure to monitor, treat, and provide appropriate interventions for hypoglycemia resulted in the resident's preventable hospitalization for further evaluation and treatment.
Plan Of Correction
F658 - Services Provided Meet Professional Standard • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 23 was transferred to acute and returned to the facility on 11/2/24. Resident 23 has no hypoglycemic episode after returning from acute. The care plan was developed and implemented. (Exhibit #11) • 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 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the list of residents receiving insulin injection to ensure blood sugar monitoring was done and meal was offered after the insulin injection to prevent hypoglycemia episode. (Exhibit #12) No other resident affected of the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Hypoglycemia Management," revised 12/19/2022. (Exhibit #13) Starting on 6/17/25, the QAN and DSD will conduct a weekly observation for three months to ensure licensed nurses are offering food and snacks after the insulin injection. (Exhibit #14) Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) The DON will also report to the administrator for any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained: The DON will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. The plan includes the following actions: - Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) - Starting on 6/17/25, the DON will report to the administrator for any non-compliance. The completion date for these actions is June 20, 2025.
Failure to Monitor Anticoagulant Therapy and Maintain Comprehensive Care Plan
Penalty
Summary
The facility failed to monitor the use of anticoagulant medication for one resident who was admitted with diagnoses including paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure. The resident was prescribed Apixaban, an anticoagulant, but the care plan related to this medication was not comprehensive or person-centered. Specifically, the care plan lacked information on monitoring for side effects such as bleeding, and there was no evidence that the resident was being monitored for these side effects as required. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the care plan did not include necessary details for monitoring the resident for adverse effects of anticoagulant therapy. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question. The deficiency was identified through review of the resident's records, care plan, medication administration record, and physician's orders.
Plan Of Correction
F755 - Pharmacy Services/Pharmacist/Records How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) included the monitoring for the anticoagulant medication for Resident 45. (Exhibit #20) 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 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents on anticoagulant medication to ensure monitoring for side effects, including bleeding, was included. (Exhibit #21) - No other resident affected of the same deficient practice. What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #22) - Beginning on 6/17/25, the QAN will review the care plan and electronic medication record (eMAR) weekly for three months of those residents who received anticoagulant medication to ensure monitoring for side effects including bleeding was indicated. (Exhibit #23) - Starting on 6/17/25, the QAN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Unlabeled and Undated Topical Medication Found in Medication Cart
Penalty
Summary
A tube of Triamcinolone Acetonide External Cream 0.5% was found in a medication cart without a label indicating the resident's name or the date the medication was opened. This medication belonged to a resident who had been admitted with type 2 diabetes and a history of falls, and who had moderate cognitive impairment. The physician's order for this medication specified its use for a rash, to be applied topically every 12 hours as needed. During an observation of the medication cart with an LVN, the unlabeled and undated tube was discovered. The DON confirmed that the medication belonged to the resident and acknowledged that all medications in the cart should be labeled and dated, with pharmacy labels including resident information. The facility's policy required all medications to be labeled and dated in accordance with state and federal regulations, including specific information such as the resident's name, prescribing physician, medication details, and appropriate instructions.
Plan Of Correction
F761 - Label/Store Drugs and Biologicals How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Licensed Vocational Nurse (LVN1) removed the Triamcinolone Acetonide External Cream 0.5% in the medication cart. 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 6/16/25 and 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) conducted a medication cart check to ensure medications stored were labeled accordingly and not expired. (Exhibit #24) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Labeling of Medications and Biologicals" dated 12/19/2022. (Exhibit #25) - Beginning on 6/16/25, the QAN and DSD will conduct medication cart checks weekly for three months to ensure medications stored were labeled accordingly and not expired. (Exhibit #26) - Starting on 6/17/25, the QAN will report to the administrator for any noncompliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025 F 761
Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum square footage as specified by federal regulations. Specifically, 33 multi-resident rooms measured less than 80 square feet per resident, and two single-resident rooms measured less than 100 square feet. This was confirmed through a review of the facility's Client Accommodation Analysis form, which listed the square footage of each room, and through interviews with the Maintenance Director and Administrator, both of whom acknowledged awareness of the room size deficiencies. The Administrator also referenced an approved room waiver dated 2025. Observations conducted during the survey period indicated that residents had sufficient space to move freely within their rooms, and there were no complaints from residents or staff regarding room size. Each resident had a bed and side table, and there was adequate space for mobility aids such as walkers, canes, wheelchairs, and shower chairs. The facility's policy and procedures required compliance with the minimum square footage standards, but the actual room sizes did not meet these requirements.
Plan Of Correction
Bedrooms Measure at Least 80 Sq Ft/Resident How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/19/25, the facility submitted a formal request for recognition of variation of room space for recertification. (Exhibit #38) 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 the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025 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 the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025
Deficiencies in Sprinkler System Maintenance and Electrical Outlet Safety
Penalty
Summary
The facility failed to provide documentation that its sprinkler system, which had been in service for 50 years, met the testing requirements set by a recognized testing laboratory or had been replaced as required by NFPA 25. During review of inspection reports, it was found that the annual sprinkler inspection failed because the sprinklers were out of date, and laboratory testing indicated the sprinklers failed the water seal release test. The facility's records also showed that a significant number of sprinklers were due for testing or replacement, and the facility's preventative maintenance policy assigned responsibility for maintenance scheduling to the Maintenance Director. Additionally, the facility did not ensure that an electrical outlet at Nurse Station #2 was properly maintained, as an observation revealed that half of the faceplate cover was broken, exposing metal terminals. This was confirmed during an interview with the CMO, who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for preventative maintenance was also reviewed in relation to this finding.
Plan Of Correction
K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring the need for regular testing and maintenance of the sprinkler system for compliance and safety. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit on the maintenance log for the sprinkler system will be done once a month for 3 months with Administrator/Designee. A summary of the identified trend of the audit will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025 K511 Utilities - Gas and Electric CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified.
Fire Alarm System Circuit Disconnect Not Properly Marked
Penalty
Summary
The facility failed to ensure that the circuit disconnecting means for the fire alarm system control unit was properly identified with a red marking, as required by NFPA 101, NFPA 70, and NFPA 72. During an observation and interview at the electrical panel, the disconnecting means labeled as "F.A." was found not to have the required red marking. The Maintenance Supervisor confirmed that the fire alarm breaker should have been marked with red, but it was not. A review of the facility's policy and procedure for the Preventative Maintenance Program indicated that a program should be in place to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the lack of proper identification of the fire alarm system's circuit disconnecting means was observed, which did not comply with the stated requirements and facility policy.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the Maintenance Supervisor (MS) placed a red marking on the fire alarm breaker. (Exhibit #1) 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: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 5/28/25, the Administrator (ADM) provided re-education to Maintenance Supervisor (MS) regarding policies and procedures entitled "Preventative Maintenance Program," to ensure that the fire alarm breaker needs to have red marking. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit of the Fire Alarm System will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness. Date of compliance: June 20, 2025
Broken Electrical Outlet Faceplate at Nurse Station
Penalty
Summary
A deficiency was identified when an electrical outlet at Nurse Station #2 was observed to have half of its faceplate cover broken, exposing metal terminals. This observation was made during a walkthrough with the Chief Medical Officer (CMO), who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for the Preventative Maintenance Program, dated 12/19/2022, assigns responsibility to the Maintenance Director for ensuring that buildings and equipment are maintained in a safe and operable manner. The exposed outlet was not protected as required by NFPA 70, 2011 Edition, Article 406.6, and this lapse was found to affect one of five smoke compartments in the facility.
Plan Of Correction
K511 Utilities - Gas and Electric CFR(s) NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) 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. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of the electrical receptacles will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability.
Failure to Post Required 'No Smoking' Signage in Oxygen Cylinder Storage Area
Penalty
Summary
Surveyors observed that a full H-sized oxygen cylinder was stored in the beauty salon, which is used as a temporary storage area when the salon is not in use. During the observation, it was noted that there was no 'No Smoking' sign posted in the area where the oxygen cylinder was stored, nor at the exterior entrances of the facility. The Chief Medical Officer (CMO) confirmed during the interview that the sign was missing and acknowledged the temporary storage practice in the salon. A review of the facility's policy and procedure titled 'Oxygen Safety' indicated that precautionary signs readable from five feet should be maintained on the door or gate where oxygen is used or stored. The lack of required signage in the area where the oxygen cylinder was stored was found to be out of compliance with NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.4. This deficiency was identified in one of five smoke compartments during the survey.
Plan Of Correction
Date of compliance: June 20, 2025 K923 Gas Equipment - Cylinder and Container Storage CFR(s): NFPA101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS posted "No Smoking signs" on the exterior of areas of the Oxygen Room and the Beauty Shop on 05/28/2025. (Exhibit #4 & Exhibit #5) 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. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Oxygen Safety, ensuring that there are "No Smoking" signs in areas where oxygen cylinders were stored. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of rooms with oxygen use will be done once a month by MS for 3 months and kept in a log. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025
Resident's Call Light and Telephone Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's touch pad call light and telephone were within reach, which led to the resident feeling frustrated and helpless. The resident, who was admitted with diagnoses including a transient ischemic attack and cognitive communication deficit, required partial assistance with toileting and used a manual wheelchair and walker for mobility. During an observation, the resident was found lying in bed, unable to reach the call light and telephone, which were positioned out of reach, causing distress as the resident could not answer a ringing phone or call for help. Interviews with the resident and staff revealed that the resident often experienced difficulty reaching the call light and telephone, leading to feelings of sadness and frustration. The resident expressed that the facility staff frequently left these items out of reach, making it challenging to communicate with family or request assistance. Staff members, including CNAs and the Director of Staff Development, acknowledged the importance of keeping call lights and telephones within reach to prevent residents from attempting to get out of bed and risking injury. The facility's policies and procedures emphasized the need to accommodate residents' needs and ensure call lights are accessible. However, the failure to adhere to these policies resulted in the resident's inability to communicate effectively and potentially delayed care. The resident's care plan also highlighted the risk for falls and the necessity of having personal items within reach, which was not consistently implemented by the facility staff.
Failure to Timely Report Unusual Occurrence
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an unusual occurrence involving a resident who sustained an acute right femoral neck fracture and a right temporal hematoma of unknown cause. The incident was not reported to the California Department of Public Health (CDPH) within the required 24-hour timeframe. This delay in reporting had the potential to result in a delay of an onsite inspection by CDPH to ensure timely investigation of injuries from unknown origins. The resident, who had a history of age-related osteoporosis, dementia, and spondylosis, was found with reddish-purple skin discoloration on the right hip and right side of the forehead. The resident was unable to recall how the injuries occurred and was in bed throughout the night. The resident complained of severe pain, rated 10 out of 10, especially when touched, and had limited range of motion. Despite these indicators, the facility's Director of Nursing (DON) and Administrator delayed reporting the incident to CDPH until they received medical confirmation of the fracture from the hospital. Interviews with facility staff revealed that the resident had been refusing to eat and receive morning hygiene care, appearing upset and unwilling to get out of bed. The facility's policy required unusual occurrences to be reported within 24 hours, but the Administrator waited until receiving the hospital's medical records before reporting. The facility's policy also indicated that physical injuries of unknown origin should be reported immediately, but this was not adhered to in this case.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nursing assistant (CNA). The incident involved a resident who was admitted with primary lateral sclerosis, generalized anxiety disorder, and was receiving palliative care. The resident was moderately cognitively impaired and dependent on assistance for all activities of daily living. The resident communicated through low sounds, spelling, pointing, and gesturing, and required a calm approach and patience from staff. The deficiency occurred when the resident became emotionally distraught after encountering CNA 1, who had previously told the resident that she smelled. This interaction caused the resident to cry hysterically, indicating significant emotional distress. The resident communicated through spelling that CNA 1 was rough, controlling, and not patient, and confirmed that the comment about her smell was hurtful. The resident's reaction was uncharacteristic, prompting a licensed vocational nurse (LVN) to report the incident to the director of staff development. Interviews with staff confirmed that the comment made by CNA 1 was considered verbal abuse, as it was perceived as hurtful by the resident and caused emotional harm. The facility's policy on abuse, neglect, and exploitation defined verbal abuse as communication that includes disparaging and derogatory terms, which was applicable in this case. The incident highlighted the need for staff to approach the resident with more sensitivity and patience due to her communication difficulties.
Failure to Develop Person-Centered Diabetes Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with diabetes, which could lead to episodes of hypoglycemia or hyperglycemia. The resident was admitted with multiple diagnoses, including type 2 diabetes, breast cancer, and immunodeficiency. Despite being admitted due to hypoglycemia and acute kidney failure, the care plan for diabetes was not initiated until 16 days after admission. The care plan lacked specific details about the diabetic medication the resident was taking and the frequency of blood sugar monitoring. The Director of Staff Development acknowledged that the care plan did not specify the insulin or other diabetic medications the resident was on, nor did it include the frequency of blood sugar checks. The facility's policy required comprehensive care plans to describe services necessary to maintain the resident's well-being, but the care plan for this resident did not meet these requirements. The deficiency was identified during a review of the resident's records and an interview with the Director of Staff Development.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to monitor the blood sugar levels of a resident with type 2 diabetes, who was receiving insulin, upon their admission. The resident was admitted with a history of hypoglycemia and acute kidney failure, and the plan of care included daily blood sugar monitoring. However, there was no physician's order for routine blood sugar checks upon admission, which led to an episode of hypoglycemia with a blood sugar level of 58. The resident was subsequently treated with orange juice and sugar, and new orders were placed to adjust insulin dosage and ensure the resident ate before taking Glipizide. Interviews with the Director of Staff Development and a registered nurse revealed that the resident should have had an order for blood sugar checks upon admission due to their insulin regimen and risk of hypoglycemia. The facility's policy indicated that residents with poorly controlled blood sugar or those taking insulin might require more frequent monitoring. The deficiency was identified as a failure to follow up with the physician regarding blood sugar monitoring orders for the diabetic resident, which could have prevented the hypoglycemic episode.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a significant deficiency with an error rate of 48.78%. This affected all five residents observed during medication administration. The errors included omitted doses, incorrect administration techniques, and failure to adhere to physician-ordered parameters. For instance, Resident 26 did not receive Metoprolol Tartrate and Clonidine as prescribed, which are critical for managing hypertension. Similarly, Resident 209 was nearly administered Furosemide and Metoprolol Succinate ER despite their blood pressure being below the physician-ordered threshold. Resident 209 also missed doses of Potassium Chloride, Apixaban, and Lactobacillus, which are essential for maintaining heart function and preventing blood clots. Resident 211 did not receive Amoxicillin for an ear infection, and Resident 210 missed the application of Lidocaine cream for pain management. Additionally, Resident 19 experienced multiple errors in medication administration via a G-tube, including incorrect techniques and failure to flush the tube as ordered, which could lead to complications. These deficiencies were observed during medication pass observations and interviews with the Licensed Vocational Nurse (LVN) responsible for administering the medications. The LVN admitted to not following up with the pharmacy or physician regarding unavailable medications and acknowledged errors in administering medications outside of prescribed parameters. The facility's failure to ensure proper medication administration placed residents at risk for significant medical complications.
Removal Plan
- A medication reconciliation for active medication orders and medication availability was completed by licensed staff for the residents listed above. Identified medication that was not available was called to the pharmacy for immediate delivery. Medications available based on physician summary orders, there were no missing medications.
- The Regional Nurse Consultant provided re-education to the Director of Nursing, the Director of Staff Development and the Infection Preventionist regarding medication administration, documentation, and medication availability. RNC observed the DON, the DSD and the IP perform medication administration.
- The pharmacy consultant reviewed physician orders and availability of the medications in the medication carts. There were no missing medications identified.
- All active licensed nurses identified were provided re-education related to medication administration, documentation, and medication availability by the Director of Nurses/Designee to include medication administration competency. Those nurses who did not have medication administration competency skill check will not be allowed to work on the floor. Medication administration competency was initiated and will continue until the eligible active licensed nurses have completed the course. Staff members on Family Medical Leave Act will be prohibited from administering medications until they have completed the competency skills. The DON, DSD, and IP observed licensed nurses conduct medication administration.
- Seven residents with g-tube were re-evaluated by licensed staff for medical complications due to potential medication administration error.
- Thirty-seven residents with medications requiring parameters were re-evaluated by licensed staff for medical complications due to medication administration error. None were identified.
- A medication reconciliation for active medication orders and medication availability were completed by licensed staff. Any identified medications not available were called to the pharmacy for immediate delivery. There were no missing medications identified.
- The Director of Nurses/Designee initiated re-education related to medication administration, documentation, medication availability, and re-ordering of medications by the Director of Nurses to include medication administration competency. Medication administration competency was conducted until active eligible Licensed Nurses completed. Staff on FMLA will not be allowed to administer meds without completing competency skills.
- The Director of Nurses initiated retraining to the night shift staff on how to audit the medication carts, re-order, and track medication. The medication cart audits will be reviewed weekly by the Director of Nursing/Designee for any necessary follow-up until substantial compliance is met.
- Quality Assurance Performance Improvement Project was implemented. The Director of Nursing / Designee will monitor medication administration and medication availability and documentation. Any trends will be discussed on Cottage Crest Post Acute monthly QA meetings.
Inadequate RNA Staffing Leads to Service Deficiency
Penalty
Summary
The facility failed to provide adequate Restorative Nursing Assistant (RNA) staff to deliver necessary restorative services, such as range of motion exercises, splint application, and ambulation, to 28 out of 54 residents enrolled in the RNA program. This deficiency was identified through interviews and record reviews, revealing that the facility's Certified Nursing Assistant (CNA) direct care hours per patient day fell below the required minimum of 2.4 hours on several occasions. The Director of Staff Development (DSD) acknowledged that the RNA staff were unavailable due to personal issues, and the facility did not utilize contracted registry staff to fill the gap, resulting in the residents not receiving the RNA services they needed. Interviews with the Director of Nursing (DON) and the Administrator (ADM) further highlighted the staffing issues, with both acknowledging the practice of pulling RNAs to work as CNAs due to short staffing. The DON admitted that residents might not receive RNA services as ordered, and the ADM was unaware of the staff shortage, despite the facility having a contract with a staffing agency. The facility's policy and procedure emphasized the importance of providing sufficient staff to ensure resident safety and well-being, yet the failure to adhere to these guidelines led to the deficiency.
Improper G-Tube Medication Administration by LVNs
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) were properly trained to administer medications via gastrostomy tube (g-tube) according to physician's orders, affecting three residents. For Resident 19, LVN 1 did not follow the physician's orders for g-tube medication administration. The nurse used a push method instead of the gravity method to administer medications and failed to flush the g-tube with the required amount of water between medications, which could lead to cross-contamination and increased risk of infection. Resident 6's case involved LVN 2, who initially prepared to administer medications without specific physician orders for g-tube administration. Although LVN 2 followed standard g-tube instructions, she acknowledged the importance of having specific orders for each resident, especially those with fluid restrictions. The nurse was stopped before administering medications, highlighting the need for clarity and adherence to physician orders. For Resident 47, LVN 5 prepared medications without checking the updated physician orders, which specified the water volume for dissolving medications and flushing the g-tube. The nurse initially used a standard method rather than the specific orders, but upon review, acknowledged the mistake and corrected the approach. This incident underscores the necessity of verifying physician orders before medication administration to prevent errors.
Medication Availability and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure the availability of several critical medications for five residents, including metoprolol tartrate, apixaban, furosemide, amoxicillin, lidocaine cream, and tussin DM. These medications were not available in stock as per physician orders or professional standards of practice. For instance, Resident 26 did not receive metoprolol tartrate due to it being out of stock, which could have led to uncontrolled hypertension. Similarly, Resident 209 did not receive apixaban, increasing the risk of stroke due to blood clots. The facility also failed to maintain accurate medication administration records for two residents. Resident 19's medication administration record was marked as if vitamin D3 was administered, although it was not given. Similarly, Resident 209's record inaccurately indicated that lactobacillus, potassium chloride, and apixaban were administered, although they were not. These inaccuracies in medication records could lead to untreated medical conditions. Interviews with the LVN and the Director of Nurses revealed that the facility did not follow its policy of reordering medications when three to five doses remained. The facility also failed to utilize the emergency kit for out-of-stock medications. The Director of Nurses acknowledged that the residents' conditions would not improve if medications were not administered on time, and the facility's actions increased the risk of serious health complications.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Expired food items, such as cilantro, Tabasco sauce, almond extract, and instant coffee grounds, were found in the refrigerator, freezer, and dry pantry. Additionally, some food items, including avocado, ginger, yellow pepper, lemon, and melons, were stored without proper labeling or expiration dates. The Dietary Manager acknowledged these issues, stating that expired items should be discarded to prevent foodborne illnesses. Improper food storage practices were also noted, with raw meats like bacon and sausages stored on the same shelves as other food items, risking cross-contamination. The Dietary Manager admitted that raw meats should be stored at the bottom to prevent contamination, especially if the packaging is open. Furthermore, the facility's policy on food storage was not followed, as vegetables were not stored in a manner that retards spoilage, and labeling was inconsistent, leading to expired items remaining in storage. The facility also failed to maintain proper hygiene practices in the kitchen. Dietary Aide 2 was observed not performing hand hygiene after removing gloves and leaving the kitchen, and again upon returning and handling clean items. Dietary Aide 1 was seen using the same gloves for multiple tasks, including handling a sanitation bucket and food preparation, which is against the facility's policy. These actions increase the risk of spreading bacteria and compromising infection control, as acknowledged by the staff involved.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not completely covering two large dumpsters and two smaller carts for an unspecified duration. This oversight was observed during a concurrent observation and interview with the Dietary Manager (DM), where it was noted that the dumpsters were full, overflowing, and their lids could not be closed. Additionally, two extra carts in front of the dumpsters were uncovered. The DM acknowledged that the trash was picked up the previous day and was scheduled for another pickup on the same day as the observation. The DM also confirmed that the garbage bins should be sealed to prevent attracting flies, rodents, and potential infestations. The facility's policy and procedure (P&P) on the disposal of garbage and refuse, revised in December 2022, mandates that containers and dumpsters must be covered when not being loaded. Furthermore, the Food Code 2017 specifies that receptacles and waste handling units containing food residue should be kept covered with tight-fitting lids or doors, especially when located outside the food establishment. This deficiency posed a potential risk of cross-contamination for 54 out of 59 residents receiving food from the kitchen.
Staffing and Medication Management Deficiencies
Penalty
Summary
The facility failed to address unresolved quality deficiencies, including issues with staffing and medication management, which were previously cited in earlier surveys. The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) from April 15 to April 20, 2024, showed that the actual Certified Nursing Assistant (CNA) direct care hours were at or below the minimum required hours of 2.4. During this period, two Restorative Nursing Assistants (RNAs) were unavailable due to personal issues, resulting in 28 residents not receiving RNA services. The Director of Staff Development acknowledged that the facility had a contract with a staffing agency but did not utilize their services, contributing to the staffing shortage. Additionally, the facility experienced significant medication errors, with a medication error rate of 48.78% observed during the Immediate Jeopardy process. Medications such as Metoprolol, Apixaban, Amoxicillin, and Lidocaine were not in stock, affecting five residents. The Administrator admitted to being unaware of these medication and staffing issues until the Immediate Jeopardy process and acknowledged that the Quality Assurance Performance Improvement (QAPI) committee meetings had not effectively resolved these issues. The facility's policy on Quality Assurance and Performance Improvement was not effectively implemented, as evidenced by the lack of corrective actions and performance improvement activities.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 7 and Resident 44, were offered and provided information regarding advance directives. Resident 7, who was readmitted to the facility with multiple diagnoses including COPD, diabetes, chronic kidney disease, and cardiomyopathy, had an incomplete Advance Health Care Directive. The directive, dated 8/24/2014, lacked the required two witnessed signatures. During interviews with the Social Services Director and the Director of Nursing, it was confirmed that the directive was incomplete, and without the necessary signatures, the staff would not be able to adhere to Resident 7's healthcare wishes. Resident 44, admitted with conditions such as end-stage renal disease, heart failure, hypertension, and diabetes, did not have an advance directive on file. The Social Services Director admitted that Resident 44 was only offered an advance directive on 6/7/2024 and could not recall offering it upon admission or quarterly as required. The Director of Nursing confirmed the absence of documentation indicating that an advance directive was offered to Resident 44. The facility's policy, dated 12/19/2022, mandates that the facility determine if a resident has an advance directive upon admission and offer one if not, which was not adhered to in these cases.
Inaccurate Documentation of Nutritional and Fall Risk Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's nutritional status on the Minimum Data Set (MDS). The MDS for one resident inaccurately indicated that the resident was receiving parenteral and enteral nutrition, which was not the case. Interviews with the Certified Nursing Assistant, Registered Nurse Supervisor, MDS Coordinator, and Director of Nursing confirmed that the resident was not receiving such nutrition and that the error was due to incorrect coding. This discrepancy in documentation could potentially affect the resident's care plan and the delivery of necessary services. Additionally, the facility did not conduct an accurate fall assessment for another resident. The resident's fall risk assessments were inconsistent with the physical and occupational therapy evaluations, which indicated the resident was at risk for falls due to physical impairments and functional deficits. Despite these evaluations, the fall risk assessments documented the resident as having normal gait and balance, and the fall risk score did not reflect the resident's true risk level. The Director of Nursing acknowledged the inaccuracies in the fall risk assessments and the lack of a timely care plan addressing the resident's fall risk. The facility's policies and procedures require accurate documentation and assessment to ensure quality resident care. However, the failure to accurately document the nutritional status and fall risk assessments for the residents indicates a lapse in adhering to these policies. The discrepancies in documentation and assessment could lead to inadequate care and services for the residents involved.
Improper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for two residents, leading to potential adverse effects. Resident 22 was administered psychotropic medications, including Seroquel and Ativan, without documented necessity for a specific diagnosed condition. The resident's care plan indicated the use of these medications for behavior management and anxiety, but there was no documentation of behavioral episodes that justified the increased dosage of Seroquel. Additionally, informed consent for the new order of Seroquel was not properly documented, and a gradual dose reduction was not attempted despite the lack of documented behavioral episodes. Resident 6 was also administered psychotropic medications, including Ativan and Sertraline, without proper documentation of anxiety and depression episodes. The care plan indicated the use of these medications for anxiety and depression, but there was no documentation of episodes that warranted their continued use. The informed consent forms for these medications were incomplete, lacking documentation of who consented and the date of consent. Despite the absence of documented behavioral episodes, a gradual dose reduction was not attempted, and the facility failed to ensure informed consent was complete before administering the medications. The facility also failed to prevent adverse effects from psychotropic medications for two other residents. Resident 25 continued to receive Seroquel for 20 days after it was ordered to be discontinued, resulting in increased confusion, lethargy, and low blood pressure, leading to hospitalization. The facility did not monitor for adverse effects of Seroquel, and the discontinuation order was not carried over to the medication administration record. Resident 34 received Risperdal and Ativan without proper indication for use and without obtaining consent for one month. These deficiencies highlight the facility's failure to adhere to policies regarding the use of psychotropic medications and monitoring for adverse effects.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents who did not receive their prescribed medications. Resident 26, who was admitted with diagnoses including end-stage renal disease and hypertension, did not receive metoprolol tartrate as prescribed due to the medication being out of stock. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not notify the resident's doctor or pharmacy about the shortage, which could have led to uncontrolled blood pressure and increased risk of stroke. Resident 209, diagnosed with paroxysmal atrial fibrillation and chronic systolic heart failure, also experienced medication errors. The LVN prepared medications for administration but failed to give potassium chloride due to nervousness and did not have apixaban in stock. The absence of apixaban increased the resident's risk for stroke due to potential blood clot formation. The LVN did not realize that the resident's blood pressure and heart rate parameters did not permit the administration of certain medications at that time. The Director of Nurses (DON) acknowledged that licensed nurses should contact the pharmacy and physician when medications are unavailable and check for out-of-stock medications in the emergency kit. The facility's policy and procedure documents emphasize the importance of timely medication administration and reordering to meet residents' needs. However, these protocols were not followed, leading to significant medication errors for the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. Certified Nurse Assistant (CNA) 1 did not perform hand hygiene during and after providing care to a resident with multiple diagnoses, including extended spectrum beta lactamase resistance and immunodeficiency. CNA 1 was observed touching the trash lid without washing or sanitizing her hands before and after wearing gloves, which she acknowledged should have been done to prevent the spread of infections. Another incident involved CNA 2, who did not wear the appropriate Personal Protective Equipment (PPE) while caring for a resident on enhanced precautions. This resident shared a room with another resident who was not on any precautions, leading to potential cross-contamination. CNA 2 admitted to forgetting about the enhanced barrier precautions and acknowledged the need to wash hands between attending to different residents to prevent cross-contamination. Additionally, during medication administration, a Licensed Vocational Nurse (LVN) failed to disinfect the medication tray or cart counter before and after administering medications to multiple residents. The LVN also did not consistently perform hand hygiene, even when handling residents with gastrostomy tubes, which are open devices that increase the risk of infection. These actions compromised infection control measures and had the potential to spread infections among residents, staff, and visitors.
Failure to Document Significant Change of Condition
Penalty
Summary
The facility failed to document a significant change of condition (COC) for a resident who was transferred to the hospital. The resident, who had a history of chronic obstructive pulmonary disease, diabetes, chronic kidney disease, and cardiomyopathy, was admitted to the facility and later readmitted with these diagnoses. Despite the resident's need for varying levels of assistance with daily activities, the facility did not document a COC when the resident was hospitalized for left lower extremity edema and abnormal vital signs. Interviews with facility staff, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that no COC documentation was completed for the resident's hospital transfer. The facility's policies require notifying the resident's physician and next-of-kin when there is a change in condition, but this was not adhered to in this case. The lack of documentation could lead to unmonitored changes in the resident's condition, as noted by the staff.
Failure to Accurately Complete PASARR Evaluations
Penalty
Summary
The facility failed to accurately assess and follow through with the Preadmission Screening and Resident Review (PASARR) process for four sampled residents, which is crucial for determining the facility's ability to meet the special needs of residents with serious mental illness, intellectual, and/or developmental disabilities. This deficiency was identified during interviews and record reviews, revealing that the PASARR evaluations were either incorrectly completed or not updated as required. Resident 22 was admitted with diagnoses including anxiety disorder, dementia, and Alzheimer's disease. Despite requiring significant assistance and being on psychotropic medications, the PASARR Level I screening incorrectly indicated that a Level II evaluation was not necessary. The Registered Nurse Supervisor acknowledged the error, stating that a new PASARR should have been submitted. Similarly, Resident 6, diagnosed with major depressive disorder, dementia, and Alzheimer's, had a PASARR Level I that correctly indicated the need for a Level II evaluation, but the Level II was not completed properly. Resident 1, with schizophrenia, mood disorder, and dementia, also had an incorrect PASARR Level I screening, which should have been positive. The Director of Nursing admitted that the PASARR process was not followed correctly for these residents, emphasizing the importance of accurate assessments to ensure appropriate care. The facility's policy requires coordination with the PASARR program to provide care in the most integrated setting, but this was not adhered to, leading to the deficiency.
Failure to Develop Timely Care Plans for Residents
Penalty
Summary
The facility failed to develop a baseline care plan for two residents, Resident 25 and Resident 36, within 48 hours of their admission, as required by policy. For Resident 25, the facility did not address multiple falls and the use of psychotropic medications in the care plan. Despite having a history of falls and being on medications such as Ativan, Rexulti, and Lexapro, the care plan was not updated to reflect these risks and interventions. The care plan for falls was only initiated on 6/6/2024, despite several falls occurring prior to this date, and there was no specific care plan for the psychotropic medications used. Resident 36, who had a history of seizures, did not have a seizure care plan initiated upon admission or after the first seizure episode on 5/1/2024. The care plan for seizures was only initiated on 6/4/2024, leaving a significant gap where no interventions or precautions were documented. This lack of a care plan meant that staff were not provided with guidance on how to manage the resident's seizure disorder, which could have led to inadequate care and increased risk of injury. Interviews with facility staff, including the Director of Nursing and Registered Nurse Supervisors, revealed that care plans should have been updated and initiated promptly to address the residents' needs and risks. The facility's policies on baseline care plans, comprehensive care plans, fall prevention, and seizure precautions were not followed, leading to deficiencies in the care provided to Residents 25 and 36.
Failure to Implement Fall Prevention Policy for High-Risk Resident
Penalty
Summary
The facility failed to implement its fall prevention policy and procedure for a resident identified as high risk for falls. The resident, who had multiple medical conditions including cerebral infarction, hemiplegia, and diabetes, experienced six falls over a period of approximately six weeks. Despite being at high risk for falls, the facility did not develop person-centered interventions or revise the resident's fall risk care plan after each fall. Additionally, the facility did not conduct post-fall assessments or proper neurological checks following the falls. The resident's care plan indicated interventions such as placing the bed against the wall and using floor mats, but these were inconsistently applied and not updated in response to the resident's changing condition. The resident was also on psychotropic medication, which increased the risk of falls, yet the facility failed to identify and address this potential risk factor. The resident's fall risk assessments consistently indicated a high risk for falls, but the care plan was not adequately revised to reflect this risk. Interviews with facility staff revealed that the care plan was not updated for each fall, and the interventions were not consistently documented. The Director of Nursing acknowledged that the care plan should have been updated and revised with each fall, but this was not done. The facility's fall prevention program policy required that each resident be assessed for fall risk and receive care and services according to their individualized level of risk, but this was not effectively implemented for the resident in question.
Failure to Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumonia vaccine, despite multiple physician orders for the vaccination. The resident, who was admitted with several medical conditions including contractures, tachycardia, dysphagia, and anoxic brain damage, was dependent on nursing staff for daily activities and did not have the capacity to make decisions. The resident's medical records indicated physician orders for the pneumococcal vaccine on three separate occasions, yet there was no documentation of the vaccine being administered or offered. The resident was transferred to a General Acute Care Hospital (GACH) due to respiratory distress and was diagnosed with pneumonia on two occasions. The Infection Prevention Nurse (IPN) confirmed the absence of documentation regarding the administration of the pneumonia vaccine and acknowledged the risk of developing pneumonia if the vaccine is not offered or given. The Director of Nursing (DON) also recognized the resident's high risk for pneumonia due to existing medical conditions and expressed uncertainty as to why the vaccine was not administered until much later.
Room Size Deficiency in Multi-Bed Rooms
Penalty
Summary
The facility failed to ensure that 33 of 33 resident rooms met the required space of 80 square feet per resident in multi-bed rooms and 100 square feet for single resident rooms. During a review of the facility's Client Accommodations Analysis form, it was found that all 33 rooms measured less than the required square footage per resident. Specifically, each of the two-bed rooms measured only 143.75 square feet, and one three-bed room measured 220 square feet, all falling short of the regulatory requirements. The Administrator acknowledged awareness of the 80 square feet per resident requirement and had previously approved a room waiver on 7/31/2023. Observations conducted from 6/4/2024 through 6/11/2024 indicated that residents had enough space to move freely within their rooms, with adequate room for the operation and use of wheelchairs, walkers, or canes. Despite the space deficiency, the room size did not affect the nursing care or privacy provided to the residents. The facility's policy and procedure on Resident Rooms, revised on 12/19/2022, stated that resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy, and should measure at least 80 square feet per resident in multiple resident bedrooms. The facility had requested and maintained variances from the survey agency for these room variances.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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