PALO ALTO SUB-ACUTE AND REHABILITATION CENTER
For profit - Limited Liability company
66 Beds
COVENANT CARE
Data: November 2025
Trust Grade
70/100
#433 of 1155 in CA
Photo by Google Maps
Photo by Palo Alto Post-Acute
Photo by Google Maps
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Palo Alto Sub-Acute and Rehabilitation Center has a Trust Grade of B, indicating it is a good choice, reflecting solid performance among nursing homes. It ranks #433 out of 1155 facilities in California, placing it in the top half, and #29 out of 50 in Santa Clara County, which means there are only a few local options that perform better. However, the facility's trend is worsening, as it reported an increase in issues from 12 in 2024 to 17 in 2025. Staffing is a strength, with a 4-star rating and a turnover rate of 40%, which is average but still means some staff stay long enough to build relationships with residents. The facility has no fines, which is a positive sign, and it offers more RN coverage than 94% of California facilities, ensuring better oversight of resident care. On the downside, recent inspections revealed several concerns regarding food quality and safety, including bland and improperly heated pureed meals, unsanitary cooking equipment, and inadequate food storage practices, which could potentially affect the health of residents. Families considering this facility should weigh these strengths and weaknesses carefully.
- Trust Score
- B
- In California
- #433/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ✓ Good
- Each resident gets 67 minutes of Registered Nurse (RN) attention daily — more than 97% of California nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 37%
No red flags
12 → 17 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 17 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below California average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near California avg (46%)
Typical for the industry
Chain: COVENANT CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 38 deficiencies on record
May 2025
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of 14 residents (8) with respect and dignit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of 14 residents (8) with respect and dignity when certified nursing assistant A (CNA A) was standing and feeding Resident 8. This failure had the potential to cause feeling of low self-esteem for the resident.
Findings:
Review of Resident 8's admission Record indicated she was admitted to the facility on [DATE].
During an observation on 5/28/25, at 12:37 p.m., CNA A was standing and feeding lunch to Resident 8 in her room.
During a concurrent interview with CNA A, she stated that she did not feel comfortable if she sat down and fed Resident 8, because she had to reach to Resident 8 to feed her. CNA A acknowledged that she could adjust the bed level and reposition Resident 8, so that she could reach to Resident 8 comfortably. CNA A stated she should sit down while feeding Resident 8.
Review of the facility's policy, Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/21/24, indicated . 5. All staff will be seated, if possible, while feeding a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident's rights to confidentiality for one ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident's rights to confidentiality for one of 14 residents (112) when the infection preventionist (IP) left her laptop screen open with Resident 112's face sheet (a document summarizing key patient information, including name, address, date of birth , emergency contact, medical history, medications, allergies, and insurance details) open and unattended on top of the stand in the hallway. This failure had the potential to compromise the resident's privacy and confidentiality.
Findings:
Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE].
During an observation on 5/27/25, at 10:55 a.m., the IP was in the hallway. Her laptop was on the stand and in front of her. The laptop was open with Resident 112's face sheet displayed on the screen. The IP left her laptop there and walked to the lobby to talk with the maintenance director. Then, the IP walked farther, across the lobby, to the other hallway to talk with other staff.
During an interview with the IP on 5/27/25, at 10:57 a.m., she confirmed that she left her laptop open with Resident 112's face sheet open and unattended in the hallway. The IP stated she should close her laptop before walking away to talk with other staff.
Review of the facility's policy, Health Insurance Portability and Accountability Act (HIPAA, a federal law that sets a national standard to protect medical records and other personal health information) Security Measures, dated 5/12/25, indicated . 8. Physical safeguards will be implemented that limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 39 and Resident 22) we...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 39 and Resident 22) were free from unnecessary psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) use when:
1. Resident 39 was administered Belsomra (Suvorexant, a sedative hypnotic medication used to treat insomnia) without informed consent (a process where the resident or their representative is educated about the risks, benefits, and alternatives to a medication before agreeing to its use), monitoring for sleep or side-effects, and a care plan addressing the medication's use.
2. Resident 22 did not have an updated informed consent when antipsychotic medication, Perphenazine (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) dose was increased.
These failures put residents at risk for adverse effects of psychotropic medications.
Findings:
1. A review of Resident 39's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included: depression (a mental health condition that causes persistent sadness and loss of interest), and schizoaffective disorder (a chronic mental health condition that includes symptoms of hallucinations or delusions).
A review of Resident 39's Order Summary Report indicated that on 5/19/25, the physician prescribed Belsomra 10 milligrams (mg, unit of measurement), to be given as one tablet by mouth at bedtime for insomnia (difficulty sleeping).
A review of Resident 39's clinical records showed no documentation of informed consent before initiating Belsomra, sleep monitoring or monitoring for side-effects, or a care plan that included the use of Belsomra or interventions.
During a concurrent interview and record review with the Director of Nursing (DON) on 5/30/25 at 10:30 a.m., the DON confirmed that there was no documented informed consent obtained before Belsomra was administered to Resident 39. There was no monitoring for sleep or side-effects recorded after the medication was started. The DON further stated that Resident 39's care plan addressed the problem of insomnia, but did not include specific interventions related to the use of Belsomra or monitoring its side-effects.
Review of facility's policy titled Use of Psychotropic Medications, revised date 2/5/25, indicated: .9) Prior to initiating or increasing psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication .the facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline .14) The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluate on an ongoing basis, such as .d) In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 15) The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record .
2. A review of Resident 22's clinical records indicated an initial admission date of 9/17/24 and diagnoses included, bipolar disorder, unspecified (a mental health condition where a person experiences extreme shifts in mood, energy, and activity levels, moving between periods of intense happiness and energy [mania] and periods of sadness and low energy [depression]) and, schizophrenia, unspecified (a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to a disconnection from reality).
A review of Resident 22's Physician order dated 5/9/25 indicated, Perphenazine Oral tablet 8 MG Give 2 tablet by mouth two times a day for Schizophrenia
During a concurrent interview and record review of Resident 22's clinical records with the DON on 5/30/25 at 12:06 p.m., the DON verified Resident 22 did not have an updated informed consent for the current Perphenazine dose. The DON verified, the informed consent indicated Perphenazine 5 mg to be given 2 tablets twice daily.
A review of the facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, .9. Prior to initiating a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered plan of care for two out of 14 sampled residents (Residents 48 and 22) when:
...
Read full inspector narrative →
Based on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered plan of care for two out of 14 sampled residents (Residents 48 and 22) when:
1. Resident 48 did not have a comprehensive care plan specific to the medication Aripiprazole (an antipsychotic medication used to treat several mental health conditions) and interventions indicated in the care plan were not followed.
2. Resident 22 did not have a comprehensive care plan specific to the medication Perphenazine (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).
These failures put residents at risk for inadequate monitoring of possible adverse effects specific to their antipsychotic medications.
Findings:
1. A review of Resident 48's clinical record indicated an admission date of 3/25/25 and diagnoses included anxiety disorder, unspecified (a mental health condition where excessive worry, fear, and apprehension interfere with daily life), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyable activities), and unspecified mood [affective] disorder (a mental health condition characterized by persistent and significant changes in a person's mood, thoughts, and behaviors).
A review of Resident 48's Physician Order indicated, Abilify Oral Tablet 5 MG [milligram, a unit of measurement] (Aripiprazole) Give 1 tablet by mouth at bedtime for UNSPECIFIED MOOD [AFFECTIVE] DISORDER M/B mood swing, hallu [hallucinations] GDR [gradual dose reduction, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose] ordered on 5/13/25.
A review of Resident 48's nursing care plan interventions initiated on 3/26/25 indicated, Complete AIMS [Abnormal Involuntary Movement Scale, used to assess the presence and severity of unwanted, involuntary movements in patients, particularly in areas like the face, mouth, limbs, and trunk] assessment every 6 months and with each increase in dose of antipsychotics
During a concurrent interview and record review of Resident 48's clinical records with the Director of Nursing (DON) on 5/30/25 at 11:50 a.m., the DON verified there was no care plan specific for the medication Aripiprazole. The DON also verified Resident 48 did not have a baseline AIMS. The DON also verified Aripiprazole had a black box warning (the strongest warning the U.S. Food and Drug Administration (FDA) can place on a drug label. It indicates a serious, life-threatening side effect or a high risk of harm associated with the medication).
During a concurrent interview and record review on 5/30/25 at 3:41 p.m. with the pharmacist consultant (PC), the PC stated a baseline AIMS would be appropriate.
A review of facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, .13. AIMS monitors Parkinsonian Symptoms [problems with movement, including shaking (tremor), stiffness (rigidity), and slow movement (bradykinesia), as well as balance issues] such as Extrapyramidal symptoms [side effects caused by certain medications, particularly antipsychotics, that affect the motor system] 14. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: d. In accordance with the nurse assessments and medication monitoring parameters consistent with the clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care .
A review of facility's policy and procedure (P&P) entitled Resident Rights revised on 3/4/25, the P&P indicated, .2. Planning and implementing care .a .iv. The right to receive the services and/or times included in the plan of care.
2. A review of Resident 22's clinical records indicated an initial admission date of 9/17/24 and diagnoses included, bipolar disorder, unspecified (a mental health condition where a person experiences extreme shifts in mood, energy, and activity levels, moving between periods of intense happiness and energy [mania] and periods of sadness and low energy [depression]) and, schizophrenia, unspecified (a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to a disconnection from reality).
A review of Resident 22's Physician order dated 5/9/25 indicated, Perphenazine Oral tablet 8 MG Give 2 tablets by mouth two times a day for Schizophrenia
During a concurrent interview and record review of Resident 22's clinical records with the DON on 5/30/25 at 12:06 p.m., the DON verified, there was no nursing care plan specific for Perphenazine. The DON stated specific medications were not included in the nursing care plan. The DON also verified Resident 22 had nursing care plans specific to other psychotropic medications (drugs that affect the brain and are used to treat mental health conditions like depression, anxiety, and schizophrenia) such as Bupropion (medication primarily used as an antidepressant ) and Sertraline (medication primarily used as an antidepressant).
A review of facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, . 14. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: d. In accordance with the nurse assessments and medication monitoring parameters consistent with the clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care .
A review of facility's policy and procedure (P&P) entitled, Comprehensive Care Plans revised 2/5/25, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of 14 residents (112) when Resident 112 was admitted with a pacemaker (electric activity-generating device used to treat patients with slow heart rates) but there was no information on the pacemaker found in his clinical record. This failure had the potential to negatively affect the resident's health, well-being, and safety.
Findings:
Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE].
Review of Resident 112's physician order, dated 5/22/25, indicated Resident 112 had a pacemaker. However, there were no information on the pacemaker such as the cardiologist information, the implant date, the device model, device serial number, lead (a wire that connects a pacemaker to the heart) model, lead serial number, battery longevity, device lower rate and maximum rate, and device checkup period found in Resident 112's clinical record.
During an interview with the director of nursing (DON) on 5/30/25, at 2:30 p.m., she reviewed Resident 112's clinical record and was unable to find the information on his pacemaker. The DON stated she would request Resident 112's pacemaker information and keep them in his clinical record.
Review of the facility's 2024 policy, Use of Pacemaker, indicated . 4. All documentation about the pacemaker will be placed in the residents' chart and part of their permanent record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents receive the pain management according to their...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents receive the pain management according to their pain levels for one of two residents (53) when the licensed nurses administered Norco (used to relieve severe pain) 5-325 milligrams (mg, a metric unit of mass) to Resident 53 when she did not have severe pain. This failure had the potential for Resident 53 to experience unnecessary adverse effects from the pain medication.
Findings:
Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE] with aftercare following joint replacement surgery diagnosis.
Review of Resident 53's physician order, dated 5/1/25, indicated she had an order for Norco 5-325 mg one tablet every 4 hours as needed for severe pain level 7-10.
Review of Resident 53's 5/2025 Medication Administration Record (MAR) indicated the licensed nurses administered Norco 5-325 mg one tablet to Resident 53 when her pain level was less than 7 on 5/4/25 at 5:09 a.m., 5/6/25 at 9:22 a.m., 5/9/25 at 05:02 a.m., 5/9/25 at 9:45 a.m., 5/10/25 at 9:56 a.m., 5/12/25 at 10:35 a.m., 5/13/25 at 9:06 a.m., 5/13/25 at 2:40 p.m., 5/14/25 at 1:07 a.m., 5/14/25 at 5:42 a.m., 5/15/25 at 8:51 a.m., 5/17/25 at 9:30 a.m., 5/17/25 at 6:25 p.m., 5/18/25 at 4:36 a.m., 5/18/25 at 11:12 a.m., 5/18/25 at 8:19 p.m., 5/20/25 at 5:10 a.m., 5/24/25 at 7:59 p.m., 5/25/25 at 2:33 p.m., 5/26/25 at 4:37 a.m., 5/26/25 at 8:34 a.m., 5/26/25 at 1:57 p.m., and on 5/27/25 at 4:35 a.m.
During an interview with the director of nursing (DON) on 5/30/25, at 2:43 p.m., she reviewed Resident 53's 5/2025 MAR and confirmed that the licensed nurses administered Norco 5-325 mg one tablet to Resident 53 when her pain level was less than 7 on 5/4/25 at 5:09 a.m., 5/6/25 at 9:22 a.m., 5/9/25 at 05:02 a.m., 5/9/25 at 9:45 a.m., 5/10/25 at 9:56 a.m., 5/12/25 at 10:35 a.m., 5/13/25 at 9:06 a.m., 5/13/25 at 2:40 p.m., 5/14/25 at 1:07 a.m., 5/14/25 at 5:42 a.m., 5/15/25 at 8:51 a.m., 5/17/25 at 9:30 a.m., 5/17/25 at 6:25 p.m., 5/18/25 at 4:36 a.m., 5/18/25 at 11:12 a.m., 5/18/25 at 8:19 p.m., 5/20/25 at 5:10 a.m., 5/24/25 at 7:59 p.m., 5/25/25 at 2:33 p.m., 5/26/25 at 4:37 a.m., 5/26/25 at 8:34 a.m., 5/26/25 at 1:57 p.m., and on 5/27/25 at 4:35 a.m. The DON stated the licensed nurses should administer pain medication to the residents according to the pain level as ordered by the physician.
Review of the facility's job description, Registered Nurse, dated 11/13/17, indicated . Medication and Treatment Administration Functions: . Complies with professional standards, policies and procedures, and legal documentation principles for administering medications, treatments, enteral, and intravenous therapies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper use of side rails or bed rails (adj...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper use of side rails or bed rails (adjustable rigid bars attached to the side of a bed) for two of 20 residents who used side rails, (Residents 19 and 28), when their side rail assessments (determine the appropriateness and safety of using side rails on a bed for an individual) were not updated in a timely manner.
This failure had the potential to place the residents at risk for entrapment (danger for the resident, being caught, trapped or entangled in the gap, space or opening) that may lead to injury or death.
Findings:
1. During an observation of Resident 19, on 5/27/25 at 10:38 a.m., Resident 19 was in bed, alert, calm, comfortable and verbally responsive. Resident 19's one fourth (quarter) side rail was up.
Review of Resident 19's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 19 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified arthropathic psoriasis (long-term inflammatory arthritis that may occur in some people affected by the autoimmune disease psoriasis).
Review of Resident 19's physician orders indicated, Resident 19 had an order on 2/21/24 for side rails for prompt bed mobility.
Review of Resident 19's side rail assessment indicated, it was last updated on 2/12/25.
During the concurrent review of the side rail assessment of Resident 19 and interview with the Director of Nursing (DON), on 5/30/25 at 1:05 p.m., the DON acknowledged that the side rail assessment of Resident 19 was not updated regularly or quarterly. The DON further acknowledged that Resident 19's side rail assessment was last updated on 2/12/25 and it should have been updated already at this time.
2. During an observation of Resident 38, on 5/27/25 at 10:30 a.m., Resident 38 was laying in his bed, alert, calm, comfortable and verbally responsive. Resident 38 had his bilateral (both sides), half side rails up.
Review of Resident 38's admission record indicated, Resident 38 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified displaced fracture (occurs when bone is broken and the broken pieces are not aligned) of third cervical vertebra (part of the seven vertebrae that makes up the neck), subsequent encounter for fracture with routine healing (healing of the fracture is progressing as expected).
Review of Resident 38's physician orders indicated, Resident 38 had an order on 2/12/25 for side rails for bed mobility.
Review of Resident 38's side rail assessment indicated, it was last updated on 1/7/25.
During the concurrent review of the side rail assessment of Resident 38 and interview with the DON, on 5/30/25 at 1 p.m., the DON verified that the side rail assessment of Resident 38 was not updated regularly or quarterly. The DON further verified that Resident 38's side rail assessment was last updated on 1/7/25 and it should have been updated already.
Review of the facility's policy and procedure titled, Proper Use of Bed Rails, implemented on October 2022 indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails .The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices .Responsibilities of ongoing monitoring and supervision are specified as follows: A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon significant change in status, or change in the type of bed/mattress/rail .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the effective use of medications for one of 14 residents (11...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the effective use of medications for one of 14 residents (112) when Resident 112 received Ferosul (iron, used for prevention/treatment of iron deficiency) and Calcium Citrate (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements.
Findings:
Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE].
Review of Resident 112's clinical record indicated, he had physician orders for Ferosul 325 milligrams (mg, a metric unit of mass) every 48 hours for anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues) at 9 a.m., started on 5/23/25, and for Calcium Citrate 250 mg every day at 9 a.m. and 5 p.m., started on 5/22/25. Thus, since 5/23/25, Ferosul and Calcium Citrate were given at the same time at 9 a.m. every 48 hours.
During an interview with the pharmacist consultant (PC) on 5/30/25, at 1:56 p.m., she stated Ferosul and Calcium Citrate should be administered at least two hours apart due to drug-to-drug interaction that decreases the absorption of iron.
According to Lexicomp (www.[NAME].com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexicomp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction.
Review of the facility's 2023 policy, Adverse Drug Interactions, indicated The pharmacy will perform an initial assessment of the complete medication profile for potential adverse drug interactions and other contraindications or precautions on all new patient orders at the time of admission. The pharmacy will perform continual and ongoing assessment of the complete medication profile for adverse interactions and other contraindications for each new order received thereafter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacist consultant's recommendation was acted upon fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacist consultant's recommendation was acted upon for one of 14 residents (115) when Resident 115's administration record on alendronate (used to prevent and treat osteoporosis [thinning of the bone]) did not include the information the pharmacist consultant asked to be included. This failure had the potential for Residents 115 to receive ineffective medication and adverse effects that could negatively impact her health and well-being.
Findings:
Review of Resident 115's admission Record indicated she was admitted to the facility on [DATE] with osteoporosis diagnosis.
Review of Resident 115's Consultation Report, dated 5/20/25, indicated the pharmacist consultant recommended to include in Resident 115's administration record on alendronate the following information: Administer intact tablet at least 30 minutes before the first food, beverage, or medication of the day with 6 to 8 ounces of plain water. Individuals should not lie down for at least 30 minutes and until after the first food of the day. However, review of Resident 115's administration record on alendronate did not indicate that the pharmacist consultant's recommendation was included.
During an interview with the director of nursing (DON) on 5/30/25, at 2:47 p.m., she reviewed Resident 115's clinical record and confirmed that the pharmacist consultant's recommendation for her alendronate was not acted upon.
Review of the facility's policy, Medication Regimen Review (MRR), dated 4/9/25, indicated . Policy Explanation and Compliance Guidelines: . 7. Timelines and responsibilities for MRR: . f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 6 residents (112) were free from unnecessary medicati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 6 residents (112) were free from unnecessary medications when Resident 112 received dabigatran etexilate mesylate (a blood thinner to prevent blood clots) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for Resident 112 to experience unrecognized adverse effects.
Findings:
Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE].
Review of Resident 112's physician order, dated 5/23/25, indicated he had an order for dabigatran etexilate mesylate 110 milligrams (mg, a metric unit of mass) two times a day. However, review of Resident 112's clinical record did not indicate that Resident 112 was monitored for the side effects and was care-planned on the use of the medication.
During an interview with the director of nursing (DON) on 5/30/25, at 2:26 p.m., she reviewed Resident 112's clinical record and confirmed that Resident 112 was not monitored for the side effects and was not care-planned on the use of the medication.
Review of the facility's policy, Anticoagulant Therapy, dated 8/2014, indicated . Procedure: . 5. Monitor for signs and symptoms of adverse drug effects, including, but not limited to, abnormal or prolonged bleeding, excessive bruising, blood in stool or urine, coffee ground emesis, bleeding from eyes, nose, or gums, etc. 8. Include anticoagulant use and monitoring in care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility had a 12% medication error rate when three medication errors out of 25 opportunities were observed during a medication pass for three o...
Read full inspector narrative →
Based on observation, interview, and record review, the facility had a 12% medication error rate when three medication errors out of 25 opportunities were observed during a medication pass for three out of five sampled residents (Residents 44, Resident 2, and Resident 8) when:
1. Resident 44 did not receive Calcium Carbonate with Vitamin D tablet (used to treat conditions caused by low calcium levels such as bone loss) as ordered by the physician.
2. Resident 2 received Diroximel Fumarate capsule (medication used for the treatment of relapsing forms of multiple sclerosis, a disease that causes breakdown of the protective covering of nerves) without food.
3. Resident 8 did not receive Fluticasone-Salmeterol inhalation (used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) as ordered by the physician.
These failures resulted in medications not given in accordance with the manufacturer's instructions and/or physician's order and had the potential for residents not receiving the full therapeutic effects of medications.
Findings:
1. During a medication pass observation on 5/27/25 at 11:27 a.m. with Registered Nurse (RN) E, RN E was preparing medications for Resident 44. RN E stated Resident 44 is due to have Calcium Carbonate with Vitamin D but was not available. RN E also stated pharmacy and physician will be notified.
A review of Resident 44's Physician Order dated 5/12/25 indicated, Calcium 600 + D oral tablet 500-5 mg-mcg [milligram-microgram, units of measurement] (calcium carbonate-vitamin D) give 1 tablet by mouth three times a day for supplement.
During a concurrent interview and record review of Resident 44's Medication Administration Record (MAR) for May 2025 with the Director of Nursing (DON) on 05/29/25 at 3:44 p.m., the DON verified Calcium Carbonate with Vitamin D was not given at 9 a.m. and 1 p.m. on 5/27/25.
A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .
2. During a medication pass observation on 5/28/25 at 4:03 p.m. with Licensed Vocational Nurse (LVN) F, LVN F was preparing medications for Resident 2 which included, Gabapentin (a medication primarily used as an anticonvulsant) 300 mg (milligram, unit of measurement) tablet, Sucralfate (medication that treats stomach ulcers) 1 gram tablet, and 2 capsules of Diroximel Fumarate 231 mg. Resident 2 took the medications with a glass of water. There was no food tray observed on Resident 2's table.
A review of Resident 2's physician order indicated, Vumerity Capsule delayed release 231 mg [milligram, unit of measurement] (diroximel fumarate) give 2 capsules by mouth two times a day for multiple sclerosis, administer at least 20 minutes after food is taken.
During a concurrent interview and record review of Resident 2's clinical record with the DON, the DON verified diroximel fumarate was scheduled to be given before dinner. The DON stated the nurse should have asked if Resident 2 had taken food. The DON also stated the medication must be scheduled after meals or a snack should be offered prior to administration.
A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, .17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid .
3. During a medication pass observation on 5/28/25 at 4:09 p.m. with Licensed Vocational Nurse (LVN) F, LVN F prepared medication for Resident 8 which included, Calcium with Vitamin D3 tablet. LVN F stated Resident 8 was due for a breathing treatment that was not available. Resident 8 took Calcium with Vitamin D3 tablet with a glass of water.
A review of Resident 8's physician order indicated, Wixela Inhub Aerosol Powder Breath Activated 250-50 mcg/act [microgram per actuation, a unit of measurement] (fluticasone-salmeterol) 1 puff inhale orally two times a day for asthma rinse mouth after each dose.
During a concurrent interview and record review of Resident 8's clinical records with the DON on 5/29/25 at 3:44 p.m., the DON verified fluticasone-salmeterol inhalation was not administered for Resident 8 on 5/28/25 due at 5 p.m.
A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored appropriately and in good sanitary condition when:
1. Medication refrigerator ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored appropriately and in good sanitary condition when:
1. Medication refrigerator had ice build up in the freezer and had a streak of yellowish-brown substance on the shelf bracket.
2. Five expired over-the-counter medications, and an opened bottle of medication for a discharged resident were found in the Central Supply Room.
These failures put residents at risk for contaminated medications and had the potential for residents to receive outdated and/or ineffective medications which could lead to residents not receiving the full benefit of the medications and negative health outcomes.
Findings:
1. During an inspection of the medication room on 5/27/25 at 10:21 a.m. with the Director of Nursing (DON), a mini refrigerator was inside. The DON confirmed there was an ice buildup in the freezer. The DON verified the ice buildup blocked the freezer door and cannot be closed and was hard to open. The DON also verified there was a streak of yellowish-brown substance found inside refrigerator on the right shelf bracket. The DON stated, We could clean it better.
A review of facility's policy and procedure (P&P) entitled Medication Storage revised 4/9/25, the P&P indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .
2. During an inspection of the Central Supply Room (CSR) on 5/27/25 at 10:30 a.m. with the DON, the DON stated over-the-counter medications and other supplies were stored in the CSR. The DON confirmed the following were stored in the CSR:
a. A bottle of Vitamin D3 125 mcg (microgram, unit of measurement) capsules with expiration date 1/2025.
b. 2 bottles of Acetaminophen 325 mg (milligram, unit of measurement) tablets with expiration date 12/2024.
c. A bottle of Acetaminophen 325 mg (milligram, unit of measurement) tablets with expiration date 8/2024
d. A tube of Zinc Oxide Formula non greasy barrier cream with expiration date 3/2025
e. An opened bottle of Pancrelipase capsules (used to improve digestion of food for people who have a condition in which the pancreas does not have enough enzymes needed to break down food so it can be digested) labeled with a discharged resident's name.
The DON stated she did not know why the expired medications were there. The DON also confirmed the opened bottle of Pancrelipase belonged to a discharged resident and should not have been there.
A review of facility's policy and procedure (P&P) entitled Medication Storage revised 4/9/25, the P&P indicated, .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE].
Review of Resident 53's physi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE].
Review of Resident 53's physician order, dated 5/25/25, indicated she had an order for oxygen 2-3 liters per minute (LPM) as needed for shortness of breath.
During an observation and interview with the infection preventionist (IP) on 5/27/25, at 10:46 a.m., the filter of Resident 53's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week.
2b. Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE].
Review of Resident 112's physician order, dated 5/22/25, indicated he had an order for oxygen 2-3 LPM continuous every shift.
During an observation and interview with the IP on 5/27/25, at 10:51 a.m., the filter of Resident 112's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week.
Review of the facility's policy, Oxygen Concentrator, dated 12/3/24, indicated . 5. Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device. f. Oxygen concentrators should have a preventive maintenance.
3. During an observation on 5/27/25, at 10:12 a.m., certified nursing assistant B (CNA B) put on gloves, picked up trash bag in Resident 12's room, walked out of the room to throw the trash bag in the hamper which was parked on the other side in the hallway with gloves on her hands. CNA B came back to Resident 12's room and prepared his bed with the same gloves on her hands. Resident 12 stated he needed mouth wash. CNA B removed her gloves but did not sanitize her hands, walked out of the room to get mouth wash from the supply room for the resident.
During a concurrent interview with CNA B, she stated she should have the hamper at the resident's room door, so she did not have to walk out in the hallway to throw the trash. CNA B stated she should remove her gloves and sanitize her hands when walking out of the resident room and in the hallway.
During an interview with the IP on 5/30/25, at 3:02 p.m., she stated staff should not walk out of resident room with gloves on and should sanitize their hands after removing the gloves.
4. During an observation on 5/28/25, at 12:28 p.m., certified nursing assistant A (CNA A) sanitized her hands, put on gloves, moved Resident 212's bed, pulled Resident 212 up, repositioned Resident 212 in bed, and raised Resident 212's head of bed up. CNA A removed her gloves and held the used gloves in her hand. Without sanitizing her hands, CNA A opened the straw and put it in Resident 212's glass of cranberry juice, removed the cover of the fruit cup, removed the lid of the lunch plate, picked up the spoon and pressed on the rice on the lunch plate with the spoon, then walked out of Resident 212's room and in the hallway to place the lid of the plate in the lunch cart without sanitizing her hands.
During a concurrent interview with CNA A, she stated she should throw the gloves in the trash can, sanitize her hands before assisting the resident with meal and when walking out of the resident room.
During an interview with the IP on 5/30/25, at 3:08 p.m., she stated staff should sanitize their hands before assisting the resident with meal and when walking out of the resident room.
Review of the facility's policy, Personal Protective Equipment (PPE), dated 6/4/24, indicated . 4. Indications/considerations for PPE use: a. Gloves: . ii. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. vii. Dispose of gloves in appropriate waste receptacle.
Based on observation, interview, and record review, the facility failed to implement infection control measures when:
1. Licensed vocational nurse F (LVN F) did not do hand hygiene in between administration of medications for two residents (Resident 2 and Resident 8);
2. The filters of Resident 53's and Resident 112's oxygen concentrators were dusty;
3. Certified nursing assistant B (CNA B) walked out of Resident 12's room with gloves on and did not sanitize her hands after removing the gloves; and
4. Certified nursing assistant A (CNA A) did not sanitize her hands before assisting Resident 212 with meal and when walking out of the resident room.
These failures had the potential to result in the transmission and spread of infection throughout the facility.
Findings:
1. During a medication pass observation on 5/28/25 at 4:08 p.m. with Licensed Vocational Nurse (LVN) F, LVN F prepared and administered oral medications to Resident 2. LVN F used gloves and did not do hand hygiene before putting on and after removing gloves. LVN F did not do hand hygiene after administering medications to Resident 2. At 4:13 p.m., LVN F proceeded to prepare and administer oral medications to Resident 8. LVN F did not do hand hygiene prior to administration of medications for Resident 8. LVN F also used gloves for Resident 8 and did not do hand hygiene before wearing and after removing gloves. LVN F verified she did not do hand hygiene in between administration of medications for Resident 2 and Resident 8 and before wearing and after removing gloves. LVN F stated hand hygiene should have been done.
During an interview on 5/29/25 at 3:44 p.m. with the Director of Nursing (DON), the DON stated, Hand hygiene must be done during medication pass in between residents.
A review of facility's policy and procedure (P&P) entitled, Hand Hygiene revised 5/29/24, the P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table:
Condition:
Between resident contacts- Either soap and water or alcohol-based hand rub
Before preparing or handling medications- Either soap and water or alcohol-based hand rub
.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that facility staff monitored and documented the side effect...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that facility staff monitored and documented the side effects of antibiotic (ATB, medication that fight bacteria) therapy for seven out of 11 residents (Residents 165, 9, 57, 267, 15, 269, and 212) who were receiving antibiotics. This failure had the potential to result in unrecognized adverse drug reactions or inappropriate antibiotic use.
Findings:
1. A review of Resident 165's admission record indicated the resident was admitted on [DATE] with diagnoses that included Tuberculosis (TB, an infectitious disease cause by bacteria that primarily affects the lungs) of lung.
A review of Resident 165's Order Summary Report indicated that on 5/11/25, the physician ordered the following antibiotics: Levofloxacin (antibiotic used to treat bacteria, including TB) 750 milligrams (mg,unit of measurement) 1 tablet to be given by mouth (PO) daily for pulmonary (lungs) tuberculosis, Ethambutal (antibiotic used to treat TB) 400 mg 3 tablets PO daily for right upper lung (RUL) cavitary lesion (an area of lung tissue damaged by infection) and Linezolid (antibiotic used to treat infection) 600 mg 1 tablet PO daily for RUL cavitary lesion.
2. A review of Resident 9's admission record showed admission on [DATE] with acute and chronic respiratory failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood), and pneumonia (a lung infection).
A review of Resident 9's Order Summary Report indicated the physician ordered Vancomycin (antibiotic used to prevent or treat bacterial infection) 50 mg/ml, 2.5 ml PO daily for prophylaxis (a preventive measure).
3. A review of Resident 57 admission record indicated the resident was admitted on [DATE] with non-rheumatic aortic valve stenosis (a narrowing of the heart's aortic valve that is not caused by rheumatic fever).
A review of Resident 57's Order Summary Report indicated the physician ordered Ciprofloxacin (antibiotic used to treat infection) 250 mg PO twice daily for UTI (infections of the bladder or urinary system).
4. A review of Resident 267's admission record indicated resident was admitted on [DATE] with osteomyelitis of the thoracic spine (a serious bone infection in the spine) and discitis in multiple spinal areas (inflammation of the discs between the bones of the spine).
A review of Resident 267's Order Summary Report, dated 5/9/25 included Ceftriaxone (antibiotic used for serious infections like bone or spine infections) 2 grams (gm, unit of mass) IV (intravenous, administered into a vein) every 12 hours for discitis (infection in the intervertebral disc space).
5. A review Resident 15's admission record indicated resident was admitted on [DATE] with chronic obstructive pulmonary disease (COPD, a long-term lung disease that makes it hard to breathe.)
A review of the facility's Antibiotic List dated 5/2025 showed that on 5/28/25, the physician ordered Cefdinir (an oral antibiotic used to treat respiratory tract infections, including pneumonia) 300 mg PO twice daily for pneumonia.
6. A review of Resident 269's admission record indicated resident was admitted on [DATE] with aftercare following a liver transplant (surgical procedure where a diseased or damaged liver is removed and replaced with a healthy liver from a donor) and cirrhosis of the liver (a condition where the liver is permanently scarred and cannot function well).
A review of the facility's Antibiotic List, indicated that on 5/21/25, Resident 269 was prescribed Bactrim (antibiotic used to prevent bacterial infections) 400-80 mg via nasogastric (NG, means the medication is given through a tube from the nose to the stomach) every Mon, Wed, and Fri as prophylaxis for organ transplant.
During an interview on 5/29/25 at 4:10 p.m., registered nurse (RN) G stated that nurses assess for rash, hives, dizziness, or other side effects during antibiotic therapy, and that documentation should be entered in the MAR (medication administration record) or progress notes.
During a concurrent interview and record review with RN H , evening supervisor, on 5/29/25 at 4:15 p.m., RN H stated that facility staff check for allergic reactions, nausea, vomiting, or changes in cognition, and this should be documented. RN H confirmed no documentation was found for side effect monitoring for the residents listed above.
During an interview with the Infection Preventionist (IP) on 5/29/25, at 4:33 p.m., the IP stated that nurses should monitor for side effects while residents are on antibiotics and document those findings.
During an interview with the Director of Nursing (DON) on 5/29/25 at 4:40 p.m., the DON confirmed that there was no documentation of antibiotic monitoring in the MAR or progress notes for the above residents. The DON stated that monitoring for side effects should be documented in the progress notes. The DON further stated that she would educate nursing staff regarding proper documentation of antibiotic therapy monitoring.
7. During an observation of Resident 212 on 5/27/25 at 10:27 a.m., Resident 212 was laying in his bed, alert, calm, comfortable and verbally responsive.
Review of Resident 212's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 212 was admitted to the facility on [DATE].
Review of Resident 212's order summary report dated 5/29/25 indicated, Resident 212 had an order of Ciprofloxacin Hydrochloride (antibiotic used to treat bacterial infections) oral tablet, 500 milligrams (mg, unit of mass), give 1 tablet by mouth two times a day for urinary tract infection (UTI, an infection that occurs in any part of the urinary system or the system of organs that makes urine), for 7 days, started on 5/23/25.
During a concurrent review of Resident 212's clinical records and interview with licensed vocational nurse D (LVN D), on 5/30/25 at 9:43 a.m., LVN D verified that Resident 212 did not have any progress notes (type of medical record used to document a patient's health status and treatment progress) for his use of Ciprofloxacin Hydrochloride antibiotic, since it was started on 5/23/25.
During a concurrent review of Resident 212's clinical records and interview with the DON, on 5/30/25 at 1:10 p.m., the DON verified that Resident 212 was on Ciprofloxacin Hydrochloride antibiotic but there was no progress notes and no monitoring for the side effects of the antibiotic use. The DON further verified that she would follow up on this concern.
Review of the facility's policy titled, Antibiotic Prescribing Practices, reviewed/revised on 5/29/24 indicated, Antibiotic use protocols, including prescribing practices, are implemented as part of the facility's Antibiotic Stewardship Program for the purpose of optimizing the treatment of infections and reducing adverse events associated with antibiotic use .Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure palatability and temperature of the foods served were maintained when:
1. The pureed (a smooth, thick liquid or paste m...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure palatability and temperature of the foods served were maintained when:
1. The pureed (a smooth, thick liquid or paste made by crushing or grinding solid foods using a blender or food processor) fish and pureed bread tasted bland (lacking taste or flavor); and
2. The temperature of the hot foods served were below the desired level.
These failures could lead to decreased nutrient intake for the 55 facility residents receiving food from the kitchen.
Findings:
1. During the test tray observation and tasting with the dietary manager (DM), on 5/28/25 at 12:45 p.m. to 12:52 p.m., two test plates in the trays were brought and tasted. One of the test plates contained regular (no modification or restriction) fish, regular vegetables and regular orzo (type of short-cut pasta that is shaped like a large grain of rice). The second test plate contained pureed fish, pureed bread, pureed vegetables and pureed orzo (pasta). Tasted the pureed foods after and the pureed fish and pureed bread had no taste or tasted bland.
During an interview with the DM after he tasted the test plate with pureed foods, on 5/28/25 at 12:53 p.m., the DM acknowledged that the pureed fish and pureed bread, tasted bland. The DM further acknowledged that he would follow up on this concern and on improving the taste of these pureed foods.
During an interview with the registered dietitian (RD), on 5/29/25 at 2:35 p.m., the RD verified that the foods to be served to the residents should be palatable and not bland in taste. The RD further verified that he would check on this concern.
Review of the facility's policy titled, Food and Dining Services Policies and Procedures: Resident Food Preferences, effective 11/2016 indicated, Satisfy resident's tastes and appetites by determining their food preferences at meals .
Review of the facility's policy titled, Food and Dining Services Policies and Procedures: Recipes, effective 2/2009 indicated, Ensure consistent food and dining quality .
Review of the facility's policy and procedure titled, Food and Dining Services Policies and Procedures: Resident Food Acceptability, effective 2/2009 indicated, Resident's acceptance of the menu and food is monitored routinely. All food and dining services staff and nursing staff are responsible for monitoring resident meal satisfaction .
2. During the test tray observation and tasting with the DM, on 5/28/25 at 12:45 p.m., the DM checked the temperatures of the foods in the two test plates in the trays that were brought, before they were tasted. The temperatures of the following hot foods were below 135 degrees Fahrenheit (F, temperature scale), which was the required temperature of the hot foods to be served in the facility:
a. regular fish - 134 degrees F;
b. regular vegetable - 125 degrees F;
c. puréed fish - 122 degrees F;
d. puréed orzo - 117 degrees F and
e. puréed bread - 114 degrees F.
During an interview with the DM on 5/29/25 at 4:35 p.m., the DM verified that the hot foods to be served to the residents should be 135 degrees F or above and temperatures of the regular fish, regular vegetables, pureed fish, pureed orzo and pureed bread were below 135 degrees F and would follow up on this concern.
During an interview with the RD on 5/29/25 at 5:03 p.m., the RD verified that hot foods served to residents should be 135 degrees F or above and would check on that issue.
Review of the facility's policy and procedures titled, Food and Dining Services Policies and Procedures: Safe Food Temperatures, effective 2/2009 indicated, Food temperatures are maintained at acceptable levels during food storage, preparation, holding, service, delivery Hot foods will be held at 135 degrees F or higher during meal service (on the tray line) .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure, cooking and kitchen equipment were maintained properly and foods in the kitchen were prepared in accordance with prof...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure, cooking and kitchen equipment were maintained properly and foods in the kitchen were prepared in accordance with professional standards for food safety when:
1. There were unsanitary cooking and kitchen equipment stored in the kitchen and,
2. Kitchen staff did not perform hand hygiene and sanitation during the tray line preparation.
These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 55 residents who received food from the facility kitchen.
Findings:
1. During the initial kitchen tour observation with the dietary manager (DM), on 5/27/25 at 9:25 a.m., observed 5 large cooking pans with brownish to blackish discolorations and rusty spots in them.
During an interview with the DM on 5/27/25 at 9:26 a.m., the DM acknowledged that the 5 large cooking pans had brownish to blackish discolorations and rusty spots and had them removed right away. He then stated that he would have them replaced.
During an interview with the registered dietitian (RD), on 5/29/25 at 2:35 p.m., the RD verified that the 5 large cooking pans with brownish to blackish discolorations and rusty spots should not be kept there in the kitchen and should have been replaced. The RD then stated that he would follow-up on that concern.
2. During the tray line preparation observation on 5/28/25 at 12:10 p.m., dietary aide C (DA C) helped in filling out the liquids of the resident meal trays in the tray carts. Observed DA C, went out of the kitchen still wearing her gloves, then went back inside and proceeded to help right away with the tray line preparation without removing her used gloves, doing hand washing and putting on new gloves before going back to helping with the tray line preparation.
During an interview with DA C on 5/28/25 at 2:35 p.m., DA C verified that she should have removed her gloves, washed her hands and put on new gloves, before she continued helping with the tray line preparation, when she went out of the kitchen and then came back right after.
During an interview with the DM on 5/28/25 at 12:55 p.m., the DM verified that DA C should have removed her used gloves, should have done hand washing and should have put on new gloves after she went out of the kitchen and before helping back with the tray line preparation, when she came back.
During an interview with the RD on 5/29/25 at 2:35 p.m., the RD verified the above concern. The RD stated that he would remind the kitchen staffs about proper hand hygiene and sanitation.
Review of the facility's policy and procedure titled, Food and Dining Services Policies and Procedures: Personnel Sanitation Standards, effective 2/2009 indicated, Maintain sanitation among food and dining services personnel. Food and dining services personnel follow sanitary standards and practices . Hands must be washed after each trip to the restroom, after leaving storage rooms, washrooms, etcetera .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise ...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.
Findings:
The room measurement indicated multiple rooms were less than 80 square feet per resident.
Room Number Number of Beds Square Feet
Per Resident
1 3 72.8
5 2 71.37
7 2 71.95
9 2 75
12 3 73.2
14 3 73.2
15 3 73.2
16 3 74
17 3 74
18 2 75
19 2 73.2
20 2 74.4
23 3 73.2
24 3 73.6
25 3 73.6
27 3 73.6
29 3 73.2
During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care.
Recommend to continue room waivers.
Feb 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for one of 3 sampled residents (Resident 16), who had diagnosis of mental illness and did not also receive a Level II screening (a comprehensive evaluation conducted by the appropriate state-designated authority to determine whether an individual has a mental disorder or an intellectual disability for the appropriate setting for the individual).
This failure had the potential to delay the care when diagnoses of mental illness was not included on the PASARR form, leading to the resident not receiving appropriate care and services in the most integrated setting appropriate to their needs.
Findings:
A review of Resident 16's admission record (face sheet, a document that gives resident's information at a quick glance) indicated, the resident was admitted to the facility on [DATE], with diagnoses that included vascular dementia (loss of memory and other mental abilities severe enough to interfere with daily life), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), delusional disorders (is a type of psychotic disorder and its main symptom is the presence of one or more delusions; a delusion is an unshakable belief in something that's untrue; the belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false) and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior).
A review of Resident #16's Preadmission Screening and Resident Review Level I Screening, dated 10/07/23 from acute hospital indicated, Resident #16 did not have a diagnosed mental disorder such as depression, schizoaffective disorder, delusional, and/or mood disorder.
A review of Resident #16's care plan, initiated 10/12/2021, indicated Resident #16 had a mood problem related to schizoaffective syndrome such as delusion and paranoid.
A review of Resident #16's Order Summary Report with active orders as of 10/10/2023, revealed an order dated 02/23/2024 and was clarified, for haloperidol (medication for mental illness) 1 milligram, one tablet by mouth at bedtime for schizoaffective syndrome.
During a concurrent interview and record review on 2/21/2024 at 3:10 PM, with the social services director (SSD), SSD reviewed Resident 16's PASARR dated 10/20/23 and confirmed that Resident #16's diagnosis of vascular dementia, depression, schizoaffective disorder, delusional, and/or mood disorder should have been on the resident's PASARR upon admission and it should have been checked for accuracy by looking over the physician's orders, face sheet and the history and physical. SSD further stated that new reassessment screening should have been created due to the following diagnosis stated above and that will be triggered PASARR level 2 screening.
Review of a facility policy titled, Resident Assessment - Coordination with PASARR Program, revised in 10/31/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) and safe use...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) and safe use of emergency medications when:
1. Random controlled medication use audit for one of seven residents (Resident 43) did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to the resident. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and
2. One of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was not replaced timely after being opened. The failure had the potential for not having emergency medications/supply on hand when needed for the residents.
Findings:
1. The Controlled Drug Record (CDR) for seven residents receiving PRN (Pro Re Nata, meaning as needed) controlled medications were requested for review during the survey.
A review of Resident 43's clinical record indicated he had a Physician order for Oxycodone (a controlled medication for pain) 5 milligrams (mg, unit of measurement) 1 tablet by mouth every 4 hours as needed for moderate pain and give 2 tablets by mouth every 4 hours as needed for severe pain, dated 2/15/24.
During a concurrent interview and record review on 2/22/24 at 2:34 P.M., with the Director of Nursing (DON), a review of Resident 43's CDR for Oxycodone and the 2/2024 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed out of the CDR on 2/18/24 at 12:51 P.M., but did not document the respective administration on the MAR. The DON acknowledged that the controlled substance medication was not accounted for in the MAR.
During an interview on 2/26/24 at 3:43 P.M., with Licensed Vocational Nurse (LVN) B, LVN B stated the controlled substance medication are counted and entered in the CDR. Then the controlled substance medication should be documented in the MAR. LVN B stated that the CDR and MAR should match. LVN B stated that the medication was not administered if not documented in MAR.
During an interview on 2/26/24 at 3:46 P.M., with the DON, the DON stated that if a medication was not documented in the MAR, that meant it was not given.
A review of the facility's General Dose Preparation and Medication Administration policy, dated 12/1/07, indicated Document the administration of controlled substances Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given on appropriate forms.
2. During a concurrent observation and interview on 2/20/24 at 10:12 A.M., with Registered Nurse (RN) C in the Medication Room, the orals e-kit (one containing oral medications) was observed unlocked without any seal. A review of the e-kit log outside the kit indicated one item (Kefzol, an antibiotic) was taken out on 2/16/24. RN C stated that when a medication was taken out of the e-kit, the withdrawal form must be faxed to the pharmacy. RN C stated the e-kit is usually replaced within 24 hours.
During an interview on 2/23/24 at 2:34 P.M., with the DON, the DON stated that the withdrawal form on the opened e-kit should be faxed to the pharmacy and the e-kit replaced within 72 hours. The DON stated that e-kits should be locked with a red seal once opened.
During an interview on 2/26/24 at 8:34 A.M., with the DON, the DON stated that non-narcotic e-kit does not need to be replaced within 72 hours.
During a review of the facility's Emergency Supplies of Medications policy, dated 12/1/07, indicated 4.1 Facility staff breaking the lock or tamper evident seal on the emergency kit should replace the lock with a tamper -evident lock or seal provided by the pharmacy and located in the emergency kit 17. For facilities served by the following pharmacies the exchange schedule will be set at a minimum of 7 days (weekly) or the state minimum if shorter, (e.g., a state requires Emergency Kit exchange must occur every 72 hours): . 17.3 Omnicare of Northern California .
According to Title 22 Licensing and Certification of Health Facilities and Referral Agencies, Section 72377 (2) Pharmaceutical Service - Equipment and Supplies, indicated Drugs used from the kit shall be replaced within 72 hours and the supply resealed by the pharmacist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:
1. Medication refrigerator temperature was not monitored t...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:
1. Medication refrigerator temperature was not monitored twice a day;
2. Resident's own medications brought from home were stored in biohazard bag and were not labeled and,
3. Five nasal sprays in medication carts were not labeled.
These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, unlabelled medications and wrong medications and could compromise residents' safety.
Findings:
1. During an inspection of the medication refrigerator at Station 2 on 2/20/24 at 10:12 a.m. with Registered Nurse (RN) C, the temperature logs indicated one type of vaccine, insulin and, infusion therapy products. The medication refrigerator temperature was not monitored twice a day. RN C acknowledged the temperature was not monitored twice a day.
During a concurrent interview and record review, on 2/22/24 at 9:45 a.m., with the Director of Nursing (DON), the DON confirmed that the medication refrigerator temperature monitoring was not consistently done twice a day. The DON stated no documentation on the temperature logs meant, it was not done.
2. During an inspection on 2/20/24 at 11:09 a.m. of Station 1 Medication Cart with RN D, RN D identified and verified, a resident's own medications which were brought from home were stored in a biohazard bag with no label. RN D stated the medications were placed in a biohazard bag to identify the resident's own medications and not mixed with the active stock. RN D, further stated the medications should not be placed in a biohazard bag and should be labeled.
3. During an observation on 2/20/24 at 11:09 a.m. with RN D, RN D identified and verified three nasal sprays without labels in the Station 1 Medication Cart.
During an observation on 2/20/24 at 11:27 a.m. with RN D, RN D identified and verified, two nasal sprays without labels in the Station 2 Medication Cart.
During an interview on 2/26/24 at 11:46 a.m. with the Director of Nursing (DON), the DON stated nasal sprays should be labeled and intended for single resident use. The DON also stated that a resident's own medications should be stored in a box or plastic bag and should be labeled. The DON further stated, it should not be placed in a biohazard bag.
Review of the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy, dated 12/1/07, indicated, 11. Facility staff should monitor the temperature of vaccines twice a day 14.1 Facility should ensure that infusion therapy products are stored at the appropriate temperature in a medication-only refrigerator .
Review of the facility's Medications Brought to Facility by the Resident/Family/Physician/Prescriber policy dated 12/1/07 indicated, 1. Facility staff should not administer medications .brought to the facility by a resident, a resident's family, or a resident's physician/prescriber, unless: . 1.2 The medication containers are clearly labeled . 2. Non-prescription medications must be kept in original container and identified with resident's name.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate food preferences for one of three residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate food preferences for one of three residents (Resident 114). This failure had the potential to result in decrease meal intake, which could compromise the resident's overall health and well-being.
Findings:
Review of Resident 114's medical record indicated she was admitted on [DATE] and had diagnoses that included diabetes (disease that affects the body's ability to control blood sugar) and muscle weakness.
During an interview with Resident 114 on 2/20/24 at 12:09 p.m., she stated the facility would serve her eggs in the morning, even though she requested not to have eggs.
During an observation and concurrent interview with Resident 114 on 2/26/24 at 8:10 a.m., accompanied by the director of nursing (DON), there were scrambled eggs on Resident 114's breakfast plate. Resident 114's tray ticket (piece of paper that shows the resident's diet order, likes, and dislikes) indicated to serve no eggs at all. The DON confirmed this observation. Resident 114 stated the facility served her eggs every morning.
The facility's policy titled Resident Food Preferences, effective 11/2016 indicated, Satisfy resident's tastes and appetites by determining and providing their food preferences at meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to ensure the call light system (system in which the resident presses a button that activates a light in the hallway to alert ...
Read full inspector narrative →
Based on observation, interview, and document review, the facility failed to ensure the call light system (system in which the resident presses a button that activates a light in the hallway to alert staff that assistance is needed) was adequately functioning for one of 15 resident bathrooms (Bathroom AA). This failure had the potential to result in residents not receiving necessary care and assistance in a timely manner.
Findings:
During an interview with Resident 43 on 2/22/24 at 1:12 p.m., he stated the facility's call light system was not functioning properly. Resident 43 stated the buttons do not work.
During an observation and concurrent interview with the director of maintenance (DOM) on 2/23/24 at 9:24 a.m., Bathroom AA was inspected. This was a bathroom shared by residents in two rooms. One of these rooms had three residents and the other had two residents. The DOM entered Bathroom AA and pushed the button that was supposed to activate the call light system. The call light in the hallway did not turn on. The DOM confirmed this observation.
During a follow-up observation and concurrent interview with the DOM on 2/26/24 at 9:55 a.m. (three days after the original observation of Bathroom AA), the DOM entered Bathroom AA and pushed the button that was supposed to activate the call light system. The call light in the hallway did not turn on. The DOM confirmed this observation.
The facility's policy titled Call Lights: Accessibility and Timely Response, revised 11/30/23 indicated, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of seventeen sampled residents, (Residents 217, 29, 47 and 220), when the activity care plans of Residents 217, 29, 47 and 220, were not comprehensive and person-centered.
These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being.
Findings:
1. Review of Resident 217's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 217 was admitted to the facility on [DATE] with diagnoses including systemic sclerosis (an autoimmune disorder in which the immune system attacks own body, affecting many systems of the body) with lung involvement, dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the mouth and/or throat) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition).
During an observation of Resident 217 on 2/20/24 at 12:50 p.m., Resident 217 was laying in her bed, alert, calm and verbally responsive.
Review of Resident 217's active physician orders as of 2/21/24 indicated, Resident 217 may participate in activities, reviewed and approved, when not in conflict with treatment, ordered on 2/2/24.
During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that the activity assistant (AA), goes to Resident 217's room for room visits and to check on Resident 217, twice per day.
Review of Resident 217's care plans indicated, Resident 217 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. Resident 217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 217's activity care plan and interview with AD, on 2/23/24 at 11:15 a.m., AD verified, Resident 217 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 217 should have comprehensive, person-centered activity care plan and she will update Resident 217's activity care plan.
During a concurrent record review of Resident 217's activity care plan and interview with the director of nursing (DON), on 2/23/24 at 2:17 p.m., DON verified, Resident 217 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 217 should have comprehensive, person-centered activity care plan.
2. Review of Resident 29's face sheet indicated, Resident 29 was readmitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra (rare spine infection, causing weakness in it's structure or pressure on the spinal cord or nerve roots), lumbar region (lower back), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) without dyskinesia (uncontrolled, involuntary muscle movement) with fluctuations (irregular shifting) and hyperlipidemia (high levels of fat particles in the blood).
During an observation of Resident 29 on 2/20/24 at 10:38 a.m., Resident 29 was sitting in his wheelchair, alert, calm and comfortable.
Review of Resident 29's active physician orders as of 2/21/24 indicated, Resident 29 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 1/19/24.
During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that they try to do one-on-one with Resident 29 in the activity room, usually with iPad (a touchscreen tablet computer, smaller than a typical laptop, made by Apple Incorporated, an American manufacturer of personal computers, smartphones, tablet computers, computer peripherals and computer software and one of the most recognizable brands in the world).
Review of Resident 29's care plans indicated, Resident 29 did not have specific activities to be provided during his one-on-one visits, in the interventions of Resident 29's activity care plan. Resident 29's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 29's activity care plan and interview with AD, on 2/23/24 at 11:18 a.m., AD verified, Resident 29 did not have specific activities to be provided during his one-on-one visits, in the interventions of Resident 29's activity care plan. AD further verified, Resident 29's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD further verified that Resident 29 should have comprehensive, person-centered activity care plan and she will update Resident 29's activity care plan.
During a concurrent record review of Resident 29's activity care plan and interview with the DON, on 2/23/24 at 2:20 p.m., DON verified, Resident 29 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 29 should have comprehensive, person-centered activity care plan.
3. Review of Resident 47's face sheet indicated, Resident 47 was readmitted to the facility on [DATE] with diagnoses including other displaced fracture (the ends of the bone have come out of alignment) of third cervical vertebra (one of the seven cervical vertebrae of the neck and the most superior one), subsequent encounter for fracture (a partial or complete break in the bone) with routine healing, type 2 diabetes mellitus (adult onset high blood sugar) and unspecified liver cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure).
During an observation of Resident 47 on 2/20/24 at 10:38 a.m., Resident 47 was sitting in his chair, alert, oriented, calm and comfortable.
Review of Resident 47's active physician orders as of 2/21/24 indicated, Resident 47 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 2/15/24.
During the interview with the activity director (AD), on 2/22/24 at 3:57 p.m., AD stated that the activity assistant (AA), goes to Resident 47's room for room visits and to check on Resident 47, twice per day.
Review of Resident 47's care plans indicated, Resident 47 did not have room visits in the interventions of his activity care plan and there were no specific activities to be provided during the room visits. Resident 47's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 47's activity care plan and interview with AD, on 2/23/24 at 11:21 a.m., AD verified, Resident 47 did not have room visits in the interventions of his activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 47's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 47 should have comprehensive, person-centered activity care plan and she will update Resident 47's activity care plan.
During a concurrent record review of Resident 47's activity care plan and interview with the DON, on 2/23/24 at 2:23 p.m., DON verified, Resident 47 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 47 should have comprehensive, person-centered activity care plan.
4. Review of Resident 220's face sheet indicated, Resident 220 was admitted to the facility on [DATE] with diagnoses including hypo-osmolality (a condition where the levels of electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia (low blood sodium), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition) and malignant neoplasm (cancerous tumor which develops when abnormal cells grow, multiply and spread to other parts of the body) of unspecified site of unspecified female breast.
During an observation of Resident 220 on 2/20/24 at 11:35 a.m., Resident 220 was laying in her bed, alert, oriented, calm and comfortable.
Review of Resident 220's active physician orders as of 2/21/24 indicated, Resident 220 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 2/5/24.
During the interview with the activity director (AD), on 2/22/24 at 4:02 p.m., AD stated that the activity assistant (AA), goes to Resident 220's room for room visits and to check on Resident 220, twice per day.
Review of Resident 220's care plans indicated, Resident 220 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. Resident 220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 220's activity care plan and interview with AD, on 2/23/24 at 11:25 a.m., AD verified, Resident 220 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 220 should have comprehensive, person-centered activity care plan and she will update Resident 220's activity care plan.
During a concurrent record review of Resident 220's activity care plan and interview with the DON, on 2/23/24 at 2:27 p.m., DON verified, Resident 220 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 220 should have comprehensive, person-centered activity care plan.
Review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 2008 indicated, It is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability and quality of life. The care plan is individualized by identified resident problems, unique characteristics, strengths and individual needs. Each plan should be realistic and have measurable goals and time frames and responsibility for meeting the specific goals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 2/20/24 at 11:00 a.m., Resident 213 was laying in bed awake, calm, and comfortable. Resident 213's b...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 2/20/24 at 11:00 a.m., Resident 213 was laying in bed awake, calm, and comfortable. Resident 213's bed had side rails.
Review of Resident 213's face sheet (a document that gives resident's information at a quick glance) indicated Resident 213 was admitted to the facility on [DATE].
Review of Resident 213's physician order dated 2/20/24 indicated, Resident 213 may have side rails to increase mobility.
Review of Resident 213's interdisciplinary team (IDT, a group of professional and direct care staff that work together to provide residents, the care that they need, when they need it) admission assessment (comprehensive type of resident evaluation), dated 2/16/24, indicated there was no documentation that the facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:40 p.m., the DON verified that Resident 213 had bed rails. She further verified that there was no documentation indicating that the facility attempted alternatives prior to installing the bed rails of Resident 213. The DON then stated that documentation should have been done, for the alternatives that were attempted prior to the installation of the bed rails.
During an observation on 2/20/24 at 11:10 a.m., Resident 32 was laying in bed, alert and comfortable. Resident 32's bed had side rails.
Review of Resident 32's face sheet indicated, Resident 32 was readmitted to the facility on [DATE].
Review of Resident 32's physician order dated 2/20/24 indicated, Resident 32 may have side rails to increase mobility.
Review of Resident 32's IDT admission assessment, dated 2/2/24, indicated there was no documentation that the facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:43 p.m., the DON verified that Resident 32 had bed rails. She further verified that there was no documentation indicating that the facility attempted alternatives prior to installing the bed rails of Resident 32. The DON then stated that documentation should have been done, for the alternatives that were attempted prior to the installation of the bed rails.
During an observation on 2/20/24 at 1:10 p.m., Resident 47 was up in his chair. Resident 47's bed had side rails.
Review of Resident 47's face sheet indicated, Resident 47 was readmitted to the facility on [DATE].
Review of Resident 47's physician order dated 2/22/24 indicated, Resident 47 may have side rails to increase mobility.
Review of Resident 47's IDT admission assessment dated [DATE] indicated, there was no documentation that the facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:45 p.m., the DON verified that Resident 47 had bed rails. She further verified that there was no documentation indicating that the facility attempted alternatives prior to installing the bed rails of Resident 47. The DON then stated that documentation should have been done, for the alternatives that were attempted prior to the installation of the bed rails.
Review of the facility's policy titled Proper Use of Bed Rails, dated 10/2022 indicated, The medical record should include an evaluation of alternatives attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's needs. The policy further indicated, Assessment should assess resident's risk of entrapment between mattress and bed rail or in the bed rail itself.
Based on observation, interview, and record review, the facility failed to follow their policy regarding use of bed rails (also called side rails, metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) for seven out of 19 sampled residents (Residents 4, 20, 21, 43, 213, 32 and 47). For Residents 4, 20, 21, 43, 213, 32, and 47, there was no documentation that indicated the facility attempted alternatives prior to installing bed rails. For Residents 20 and 43, there was no documentation that indicated the facility assessed for risk of entrapment (getting caught, trapped, or entangled in the space in or around the bed rail). This failure had the potential to compromise the residents' safety.
Findings:
1. During an observation on 2/21/24 from 9:41 a.m. to 9:58 a.m., the beds of Residents 4, 20, 21, and 43 were inspected. All of these residents' beds had bed rails.
Review of Resident 4's medical record indicated she had a physician's order, dated 2/20/24 for, Ok to have side rails to increase bed mobility. There was no documentation in the medical record that indicated the facility attempted alternatives prior to installing Resident 4's bed rails.
Review of Resident 20's medical record indicated he had a physician's order, dated 2/21/24 for, Ok to have side rails for prompt bed mobility. There was no documentation in the medical record that indicated the facility attempted alternatives prior to installing Resident 20's bed rails. There was also no documentation that indicated the facility assessed Resident 20 for risk of entrapment.
Review of Resident 21's medical record indicated she had a physician's order, dated 2/20/24 for, OK to have side rails to increase bed mobility. There was no documentation in the medical record that indicated the facility attempted alternatives prior to installing Resident 21's bed rails.
Review of Resident 43's medical record indicated he had a physician's order, dated 2/21/24 for, Ok to have side rails to prompt bed mobility. There was no documentation in the medical record that indicated the facility attempted alternatives prior to installing Resident 43's bed rails. There was also no documentation that indicated the facility assessed Resident 43 for risk of entrapment.
During an interview and concurrent record review with the director of nursing (DON) on 2/21/24 at 10:29 a.m., she confirmed the above residents had bed rails. The DON reviewed the medical records of Residents 4, 20, 21, and 43 and confirmed there was no documentation that indicated the facility attempted alternatives prior to installing their bed rails. The DON also confirmed for Residents 20 and 43, there was no documentation that indicated the facility assessed for risk of entrapment. The DON acknowledged the facility was supposed to attempt alternatives prior to installing bed rails and assess for risk of entrapment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 2/20/24 at 10:58 a.m. with Registered Nurse (RN) C, of the treatment cart, the treatment cart was ob...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 2/20/24 at 10:58 a.m. with Registered Nurse (RN) C, of the treatment cart, the treatment cart was observed with an open suture removal kit, laptop with the charger and mouse mixed with skin protectant and wound dressing supplies in one of its drawers.
During an interview on 2/20/24 at 10:58 a.m., with the Director of Nursing (DON), the DON stated that an open suture removal kit, laptop with charger and mouse should not be mixed with the skin protectant and wound dressing supplies in a drawer in the treatment cart.
During an interview on 2/23/24 at 11:36 p.m., with Infection Preventionist (IP), IP stated that the open package of suture removal kit, laptop, charger, and mouse should not be in the treatment cart to prevent spread of infection. IP stated that the open suture removal kit should be discarded once opened and not kept in the treatment cart.
Review of the facility's Safe, Clean, Comfortable, and Homelike Environment policy, dated 6/2023, indicated 10. The facility will strive to maintain/enhance a safe, clean, comfortable environment by engaging in the following general practices and consideration: . e. maintaining chemicals, cleaning agents, and biologicals in a safe and secured manner.
Review of the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy, dated 12/1/07 indicated, 3.5 Topical (external) use medications or other medications should be stored separately .when infection control issues may be a consideration.
3a. During an observation on 2/20/24 at 1:03 p.m., Resident 38 was observed lying in bed with a nasal cannula tied around the side rails without a date and not placed in a bag.
During an interview on 2/20/24 at 2:55 p.m., with the DON, the DON stated that oxygen tubing is changed every 30 days and must be labeled with the date it was changed. The DON stated that nasal cannula tubing must be placed in a bag when not in use by the resident.
Review of the facility's Oxygen Administration policy, dated August 2014, indicated 5. g. Label humidifier with date and time opened. Change humidifier and tubing per facility procedure 10. At regular intervals, check and clean oxygen equipment, masks, tubing and cannula.
3b. During an observation on 2/20/24 at 1:35 p.m., Resident 54 was in bed with the urinary catheter drainage bag without a privacy bag.
During a concurrent observation and interview on 2/20/24 at 1:43 p.m., with Licensed Vocational Nurse (LVN) A, LVN A confirmed that the urinary drainage bag has no privacy bag.
During an interview on 2/20/24 at 1:50 p.m. with the IP, the IP confirmed that the urinary catheter drainage bag has no privacy bag. IP stated that there should always be a privacy bag.
Review of the facility's Catheter Care policy, dated 1/11/22, indicated Privacy bags will be available and catheter drainage bag will be covered at all times while in use.
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. Resident 163's unlabeled nebulizer mask [(similar to a regular oxygen mask; it covers the mouth and nose and is usually held onto the face using an elastic band, the nebulizer is used to deliver liquid medication via inhalation to the lungs by converting the liquid drug into a fine mist) tubing and the Bi-level Positive Airway Pressure (BIPAP, machine that help push pressurized air into the lungs) mask tubings were exposed and touching the bedside table and, the oxygen (O2) nasal cannula (NC, a plastic tubing that delivers oxygen) tubing was not labeled.
1a. Resident 163's unlabeled nebulizer face mask tubing, BIPAP mask tubing, O2 - NC tubing and suction tubing were touching the urinal.
1b. Resident 44 is on contact isolation (a combination of practices used to prevent germs from spreading) due to Clostridium difficile (C. diff., a bacterium which can infect and make humans ill) and her commode was outside her room next to the isolation cart.
1c. Housekeeping cart bucket has two unlabeled plastic bottle sprays with liquids inside approximately 800 ml. (milliliter, a unit of measure) each spray bottle and one box opened gloves inside the plastic container with eight pairs of gloves outside the box together with pen, cell phone and notebook.
2. For Resident 57, the gastrostomy tube (GT, a feeding tube surgically inserted through the abdomen and into the stomach) formula and administration tubing were unlabeled and undated;
3. Open suture removal kit, laptop with charger and mouse, skin protectant and wound dressing supplies stored in one drawer of the treatment cart.
3a. Nasal cannula tied on the side rails without a date and not placed in a plastic bag for Resident 38.
3b. Urinary catheter drainage bag without a privacy bag.
These failures could result in the spread of infection and cross-contamination that could affect the 60 residents who reside in the facility.
Findings:
1. During an initial tour of the facility on 2/20/24 at 9:01 a.m., Resident 163's nebulizer mask tubing, BIPAP mask tubing and O2 NC, were not labeled with a date to indicate when the tubings were applied or changed and were touching the bedside table.
During a concurrent observation and interview on 2/20/24, at 9:17 a.m., with the infection preventionist (IP), she acknowledged the above observation and stated that nebulizer mask tubing, BIPAP mask tubing and O2 NC, should not be touching the bedside table surface and it should be put inside the plastic bag for good infection control practice.
During a concurrent interview and record review on 2/23/24 at 10:05 a.m., with the director of nursing (DON), She reviewed Resident 163's clinical records and stated that Physician order dated 2/19/24 indicated 02 at 2-4 Liter/ minute (L/Min.) via NC, continuous every shift, change 02 tubing monthly every night shift (every 28 days), BIPAP on at 9:00 p.m., and off at 9:00 a.m., and wash BIPAP tubing, headgear, and whisper swivel adapter (if utilized) weekly - every Sunday. DON further stated that 02 NC, BIPAP and nebulizer tubings should have been labeled when the tubing was applied or changed, and stored in a clean plastic bag if not used.
1a. During an initial tour of the facility on 2/20/24 at 9:13 a.m., Resident 163's nebulizer mask tubing, BIPAP mask tubing, suction machine tubing and O2 NC tubing, were touching the urinal.
During a concurrent observation and interview on 2/20/24, at 9:17 a.m., with the infection preventionist (IP), she acknowledged the above observation and stated that they should not be touching the urinal due to infection control issue.
Review of the facility's policy and procedure titled CPAP/BIPAP Cleaning revised 6/15/2023 indicated, 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. 3. Staff shall perform hand hygiene and wear gloves whenever touching the CPAP/BIPAP equipment 6. clean mask frame daily after use with CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open while one is asleep)/BIPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use.
1b. During an initial tour of the facility on 2/20/24 at 9:02 a.m., a commode was outside Resident 44's room next to the isolation cart.
During a concurrent observation and interview on 2/20/24 at 9:03 a.m., with the housekeeper E (HKE), HKE stated that the commode was used by resident 44 and was cleaned this morning.
During a concurrent observation and interview on 2/20/24 at 9:03 a.m., with the IP, she confirmed the above observation and stated that Resident 44 is on contact isolation due to C. diff. and Resident 44's bedside commode should not be outside her room next to the isolation cart due to infection control issue and she further stated that the staff should follow the contact precaution protocol for all residents in contact isolation.
1c. During a concurrent observation and interview on 2/20/24 at 9:04 a.m., with the HKE she acknowledged there were two unlabeled plastic bottle sprays with liquids inside and one box opened, gloves inside the plastic container with eight pairs of gloves outside the box together with pen, cell phone and notebook in the housekeeping cart.
During a concurrent observation and interview on 2/20/24 at 9:14 a.m., with the IP, she confirmed the above observation and stated that the staff should follow the infection control protocol for all residents in order to prevent the spread of infections in the facility.
Review of the facility's policy and procedure titled Safe, Clean, Comfortable, and Homelike Environment dated 6/2023, indicated in accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable and home like environment .10. The facility will strive to maintain/enhance a safe, clean, comfortable environment by engaging in the following general practices and consideration: . c. Properly labeling and /or storing personal/ADL supplies when not in use e. maintaining chemicals, cleaning agents, and biologicals in a safe and secured manner.
2. Review of Resident 57's medical record indicated he was admitted on [DATE] and had the diagnosis of acute pancreatitis (a condition where the pancreas becomes inflamed).
Review of Resident 57's Order Summary Report indicated he had a physician's order, dated 2/19/24, to administer Osmolite 1.5 (a type of GT formula) via enteral pump (machine that delivers GT formula) and infuse at 70 milliliters per hour (rate of delivery) for 12 hours.
During an observation in Resident 57's room on 2/20/24 at 1:01 p.m., there was a metal pole near Resident 57's bed with a bottle of Osmolite 1.5 hanging from the top of the pole. Some of the Osmolite 1.5 had already been administered, as the bottle was not full and the GT administration tubing was already attached to the bottle. The Osmolite 1.5 bottle and the administration tubing were both unlabeled and undated.
During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 2/20/24 at approximately 1:05 p.m., LVN A entered Resident 57's room and confirmed his bottle of Osmolite 1.5 and the attached GT administration tubing were unlabeled and undated.
During an interview with the director of nursing (DON) on 2/20/24 at 1:20 p.m., she confirmed GT formula bottles and administration tubings were supposed to be labeled and dated so staff would know how long they have been in use.
During an observation on 2/26/24 at 12:46 p.m., an unopened bottle of Osmolite 1.5 and an unopened GT administration tubing package were inspected. On the bottle of Osmolite 1.5, there was a label with sections designated to write the resident's name, room number, the date, start time, and formula infusion rate. Inside the GT administration tubing package, there was a label with sections designated to write the resident's name, room number, formula, date and time, and expiration date.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when:
1. There was an unlabeled an...
Read full inspector narrative →
Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when:
1. There was an unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen;
2. There was a dented can of kidney beans in the dry storage area of the kitchen;
3. There was no internal thermometer in two kitchen freezers; and
4. There were multiple brown substances on the metal racks in the kitchen reach-in refrigerator.
These failures had the potential to cause food contamination and spread foodborne illness to all residents who received their food from the kitchen.
Findings:
1. During an observation and concurrent interview with the dietary manager (DM) on 2/20/24 at approximately 8:56 a.m., there was one unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen. The DM confirmed this observation and stated everything should have a label with the date the food was received.
The facility's undated document titled Cook Training/Orientation Checklist indicated, Cover, date, and label stored foods.
2. During an observation and concurrent interview with the DM on 2/20/24 at approximately 8:58 a.m., there was a dented can of kidney beans in the dry storage area of the kitchen. The dented can was stored together with non-dented cans that were intended for resident consumption. The DM confirmed this observation and explained there was a designated area in his office where dented cans should be placed.
The facility's policy titled Food Receiving, dated 2/2009 indicated, When unpacking items, you must inspect goods for damage. If you have dented cans or open packages, label them do not use and put them in the supervisor's office to be sent back to the supplier for credit.
3. During an observation and concurrent interview with the registered dietician (RD) on 2/20/24 at approximately 9:05 a.m., three reach-in freezers in the kitchen were inspected. The reach-in freezers had a small screen on the outside that displayed the freezer temperatures. One of the three reach-in freezers had an internal thermometer. The other two reach-in freezers did not have an internal thermometer. The RD confirmed this observation, but was not sure if the reach-in freezers needed to have internal thermometers.
The facility's policy titled Food Safety In Receiving and Storage, dated 2/2009 indicated, A thermometer will be kept in each refrigerator and freezer unit. Cooler and freezer temperatures will be checked and recorded daily, using the internal thermometers.
The facility's undated policy titled Food & Dining Services Equipment Cleaning Procedures indicated, Freezer: . 5. Verify that there is a thermometer inside the unit.
4. During an observation and concurrent interview with the DM on 2/20/24 at approximately 9:20 a.m., the kitchen's reach-in refrigerator was inspected. The reach-in refrigerator had multiple metal racks with food stored on them. There were multiple brown crusty substances spread throughout all of the metal racks. The DM confirmed this observation.
During a follow-up observation and concurrent interview with the DM on 2/21/24 at 8:02 a.m., the kitchen's reach-in refrigerator was inspected again. The brown crusty substances were no longer on the metal racks. The DM confirmed these were the same metal racks from the previous day, but they had been cleaned with soap and water.
The United States Food and Drug Administration's 2022 Food Code indicated equipment shall be clean to sight and touch.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure garbage was stored properly when the lid for the outside dumpster was not closed. This failure had the potential to ...
Read full inspector narrative →
Based on observation, interview, and document review, the facility failed to ensure garbage was stored properly when the lid for the outside dumpster was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility.
Findings:
During an observation and concurrent interview with the dietary manager (DM) and registered dietician (RD) on 2/21/24 at 8:15 a.m., the facility's outside dumpsters were inspected. There was one dumpster designated for garbage. This dumpster had garbage bags inside that were situated in such a way that the bags were stacked above the dumpster's brim, and the dumpster lid was not able to close. Both the DM and the RD confirmed this observation. The DM looked inside the garbage dumpster and stated there was actually more room inside. The DM rearranged the garbage bags and the dumpster lid was then able to close. The RD confirmed the lid to the garbage dumpster should have been closed.
The facility's policy titled Garbage & Rubbish Disposal, dated 2/2009 indicated, 2. All containers are provided with tight-fitting lids or covers 5. Garbage and rubbish containing food waste shall be stored so as to be inaccessible to vermin 8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area.
The United States Food and Drug Administration's 2022 Food Code indicated, Refuse [waste], recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise ...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.
Findings:
The room measurement indicated multiple rooms were less than 80 square feet per resident.
Room Number Number of Beds Square Feet
Per Resident
1 3 72.8
5 2 71.37
7 2 71.95
9 2 75
12 3 73.2
14 3 73.2
15 3 73.2
16 3 74
17 3 74
18 2 75
19 2 73.2
20 2 74.4
23 3 73.2
24 3 73.6
25 3 73.6
27 3 73.6
29 3 73.2
During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care.
Recommend to continue room waivers.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident for one of two sampled residents (Resident 1). This failur...
Read full inspector narrative →
Based on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident for one of two sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety.
Findings:
Review of Resident 1 medical record indicated she was admitted to the facility with diagnoses that included bipolar disorder (a mental disorder which a person can experience periods of overly happy or periods of feeling sad). The medical record indicated Resident 1 was discharged from the facility on 4/5/23.
During an interview with the administrator (ADM) on 7/12/23 at 9:36 a.m., the ADM stated the facility was not aware of Resident 1's allegation of abuse, until the police walked into the facility on the evening of 7/11/23. The ADM stated Resident 1 went to a local hospital and reported that the alleged abuse happened 4/8/23 when certified nursing assistant A (CNA A) had put a hot towel on Resident 1's groin area on purpose.
During an interview with the ADM on 1/31/23 at 7:55 a.m., the ADM stated the facility did not do a formal investigation of the allegation. The ADM confirmed, the facility did not send a 5-day summary to the California Department of Public Health (CDPH).
During an interview with ADM on 1/31/24 at 7:55 a.m., the ADM stated he did not send the 5-day summary to CDPH, and could not find a fax confirmation to verify if the document was sent to CDPH.
A review of the facility's policy and procedure (P&P), titled Alleged or Suspected Abuse and Crime Reporting, revised 10/2022, the P&P indicated .6. Investigation: Injuries of unknown source, suspected or alleged abuse, neglect, .will be investigated with results reported in accordance with facility policies and federal and state regulations.
Apr 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) had a Minimum Data...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) had a Minimum Data Set (MDS, an assessment tool) Significant Change in Status Assessment (SCSA) completed when Resident 17 was discharged from hospice care (physical and emotional care for the terminally ill). This failure had the potential to result in Resident 17 not receiving necessary care and treatments.
Findings:
A review of Resident 17's admission Face Sheet indicated the resident was admitted to the facility on [DATE] with multiple diagnoses that included hemiparesis (weakness or the inability to move on one side of the body) following unspecified cerebrovascular disease (relating to the brain and its blood vessels) affecting left non-dominant side, cerebella stroke syndrome (blood flow to the brain is interrupted).
Review of Resident 17's minimum data set (MDS, an assessment tool), dated 2/10/22, indicated Resident 17 had a brief interview for mental status (BIMS) score of 1 (a score 0 - 7 indicates severe cognitive [thinking, reasoning, or remembering] impact).
A review of Resident 17's physicians orders, dated 4/1/22, indicated Resident 17 was admitted to hospice care effective 8/4/21.
During an interview, on 4/6/22 at 3:01 p.m., Resident 17's Responsible Party (RP) stated Resident 17 was not currently on hospice care, it was stopped about 1 to 2 months ago.
During an interview on 4/7/22 at 9:30 a.m. with the Social Services Director (SSD) and the Case Manager Licensed Vocational Nurse (LVN) B, LVN B stated Resident 17 graduated from hospice care on 1/30/22.
A review of Resident 17's nursing progress notes, dated 1/30/22 at 3:32 p.m., indicated, Hospice care was discontinued 1/30/22 .
During an interview on 4/7/22 at 4:55 p.m. with the Director of Nursing (DON), the DON stated an order should have been placed when the resident was discharged from hospice care on 1/30/22. The MDS coordinator and the Interdisciplinary Team (IDT) would then complete their assessments.
During a concurrent interview and record review with the MDS Coordinator (MDSC) on 4/8/22 at 12:07 p.m., the MDSC stated an MDS Significant Change in Status Assessment (SCSA) should have been completed when Resident 17 was discharged from hospice care, then the IDT would have reviewed and updated the care plans. The MDSC confirmed there was no evidence the SCSA was completed when Resident 17 was discharged from hospice and there was no evidence Resident 17's care plans were reviewed and revised.
A review of the facility's policy Care Plan, Comprehensive, dated [DATE], indicated It is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. It is reviewed and revised by the Interdisciplinary Team quarterly, following completion of the MDS assessment, and following assessment for significant change.
A review of the CMS RAI manual, dated October 2019, indicated that a significant change in status assessment must be completed .when the resident comes off the hospice benefit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 residents (Resident 20) received necessary and pro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 residents (Resident 20) received necessary and proper care and services when Resident 20's psychological evaluation (used to determine a resident's mental state and guide recommendations for the best treatment) was not done as requested by the physician.These failures had the potential to affect the residents' care, health and well-being.
Findings:
Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks).
Review of Resident 20's physician order indicated he had orders for divalproex (used to treat the manic phase of bipolar disorder) 2000 mg every day for bipolar disorder, started on 3/19/21, quetiapine (used to treat bipolar disorder) 200 mg two times a day for bipolar disorder, started on 3/26/21, and trazodone (used to treat sleep disorder) 100 mg at bedtime for insomnia (trouble falling asleep, staying asleep, or both), started on 11/19/2020.
Review of Resident 20's Consultation Report, dated 9/10/21, indicated the consultant pharmacist noted Resident 20 had received antipsychotic (a class of medication used to manage a range of psychotic disorders) and Resident 20 was due for medication evaluation. The physician accepted the consultant pharmacist's recommendation and requested a psychological evaluation to be implemented. There was no psychological evaluation done for
Resident 20.
During an interview on 4/8/22 at 12:53 p.m., the director of nursing (DON) reviewed Resident 20's clinical record and confirmed Resident 20 did not have a psychological evaluation as requested.
Review of the California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
b. During an initial tour on 4/4/22 at 9:00 a.m., a bottle of diluted Dakin's solution (a skin disinfectant to cleanse wounds in order to prevent infection), containing 473 milligrams (mg, unit of dos...
Read full inspector narrative →
b. During an initial tour on 4/4/22 at 9:00 a.m., a bottle of diluted Dakin's solution (a skin disinfectant to cleanse wounds in order to prevent infection), containing 473 milligrams (mg, unit of dose) per milliliter (ml, a unit of volume), was placed on Resident 193's bedside table with a glass of water next to it. Resident 193 stated he obtained the solution from an acute care hospital and had been using it daily to clean his right leg wound, since his admission to the facility on 3/16/22. Resident 193 stated he kept the solution on his bedside table.
Review of Resident 193's clinical record indicated the resident had diagnoses including an unspecified open wound on the right lower leg and foot ulcer.
During an observation and interview on 4/4/22 at 9:04 a.m., RN C stated Resident 193's bottle of diluted Dakin's solution should have been kept in the treatment cart instead of on the resident's bedside table.
c. During an observation and concurrent interview with RN C, on 4/4/22 at 9:50 a.m., in Resident 24's room, one tube of Neosporin ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) was placed on the bedside table, and unattended. RN C stated the resident's Neosporin ointment should have been kept inside the treatment cart and locked.
During an interview on 4/4/22 at 10:00 a.m., licensed vocational nurse I (LVN I) stated all medications, treatment items, and biologicals are securely stored in a locked cart.
During an interview on 4/5/22 at 11:00 a.m., Resident 24 stated she kept Neosporin ointment in her stand drawer and used it for her forearm, daily and as needed.
Review of the facility's policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, dated 1/3/2017, indicated the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors Bedside Medication Storage: Facility should store bedside medications or biologicals in a locked compartment within the resident's room Facility should ensure that only facility representatives and the appropriate resident maintains the keys, access cards, electronic codes or combinations which open the locked compartment.
Based on observation, interview, and record review, the facility failed to store medications appropriately when the following were observed:
1. Two of three medication carts were left unlocked and unattended; and,
2. For Residents 295, 193, and 24, medications were left at their bedside.
These failures had the potential to result in the access of medications by unauthorized personnel or residents.
Findings:
1. During an observation on 4/4/22 at 11:28 a.m., the medication cart at Station 2 was unlocked and unattended.
During an observation on 4/4/22 at 11:31 a.m., two visitors passed by the unlocked medication cart.
During an interview on 4/4/22 at 11:33 a.m., registered nurse C (RN C) confirmed she forgot to lock the medication cart and stated the medication cart should be locked. RN C stated if the medication cart was left unlocked and unattended, anybody can get to the medications inside.
During a medication pass observation on 4/5/22 at 8:20 a.m., registered nurse D (RN D) prepared medications for Resident 3.
During concurrent observation and interview on 4/5/22 at 8:31 a.m., RN D stated she need to get an item from her medication cart. After opening the medication cart and removing an item, RN D left the medication cart unlocked. RN D left the medication cart unattended as she administered medication to Resident 3.
During an interview on 4/5/22 at 8:42 a.m., RN D stated the medication cart was supposed to be locked.
2. a. During a medication pass observation on 4/5/22 at 8:26 a.m., RN C prepared medications, including MiraLAX (medication to treat constipation), for Resident 295. RN C mixed MiraLAX in a cup of water.
During an observation on 4/5/22 at 8:48 a.m., RN C administered the medications to Resident 295. Resident 295 took sips of the MiraLAX, did not finish the MiraLAX and Resident 295 placed the cup on his bedside table. RN C did not instruct Resident 295 to finish the MiraLAX.
During an observation on 4/5/22 at 9:18 a.m., the cup of MiraLAX was on Resident 295's bedside table as RN C continued to prepare medications for other residents.
During a concurrent interview, RN C stated she did not check if Resident 295 finished all of the MiraLAX.
Review of the facility's policy, Medication Administration Operating Standard Guideline, dated 12/2012, indicated medication carts and rooms should be kept locked unless within eyesight of a licensed nurse and make sure the resident swallows the medication and observe that the resident is not having difficulty swallowing, and that they consume all the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise ...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.
Findings:
The room measurement indicated multiple rooms were less than 80 square feet per resident.
Room Number Number of Beds Square Feet
Per Resident
1 3 72.8
5 2 71.37
7 2 71.95
9 2 75
12 3 73.2
14 3 73.2
15 3 73.2
16 3 74
17 3 74
18 2 75
19 2 73.2
20 2 74.4
23 3 73.2
24 3 73.6
25 3 73.6
27 3 73.6
29 3 73.2
During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care.
Recommend to continue room waivers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards and receive adequate supervision during smoking sessions to prevent accidents for three of five sampled residents (Residents 92, 192, and 193). When:
1. Resident 92 was not assessed for smoking safety upon admission, was not provided adequate supervision during smoking sessions, and the facility did not initiate smoking care plan timely; and,
2. For Residents 192 and 193, the residents had no smoking assessment and smoking related care plans upon admission and facility staff did not provide supervision during the scheduled smoking time.
This failure had potential to cause smoking related accidents/harm of these residents
Findings:
1. Review of Resident 92's clinical record indicated he was admitted on [DATE] with infection of left hip joint, chronic kidney disease (a gradual loss of kidney function), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). There was no smoking safety assessment done and care plans related to smoking were not initiated.
During a concurrent observation and interview on 4/4/22, at 8:35 a.m., in Resident 92's room, an unopened pack of cigarettes was observed on the bedside table. Resident 92 stated he kept the cigarettes and lighter on his own.
During an observation on 4/4/22 at 10:20 a.m., Resident 92 was smoking outside with another resident at the designated smoking area without supervision.
During an observation on 4/5/22, at 10:15 a.m., Resident 92 was smoking at the designated smoking area without supervision.
During a concurrent interview and record review, on 4/6/22 at 10:31 a.m., with the director of nursing (DON) regarding smoking safety assessment, she stated that licensed nurses were responsible for completing the smoking safety assessment upon admission and facility staff should keep both the cigarettes and lighter. The DON further stated that staff should provide smoking supervision even if the resident is independent.
During a concurrent interview and record review, on 4/6/22 at 1:18 p.m., the DON reviewed Resident 92's clinical record and confirmed there was no smoking safety assessment done upon admission and smoking related care plans were not initiated timely.
2. During a concurrent observation and interview, on 4/4/22 at 12:13 p.m., with Resident 192, he took one open pack of cigarettes and a lighter out of his pocket and stated that he kept the cigarettes and lighter on his own. Resident 192 stated he smoked in the parking area without facility staff supervising him.
During an observation, on 4/4/22 at 2:30 p.m., Resident 192 was smoking at the designated smoking area by himself without facility staff supervision. An open pack of cigarettes and a lighter were placed on the side of his wheelchair.
During an observation on 4/5/22 at 8:15 a.m., Resident 192 was smoking at the designated smoking area by himself without facility staff supervision, with an open pack of cigarettes and a lighter on the side of his wheelchair.
During a concurrent observation and interview with Resident 192, on 4/5/22, at 8:30 a.m., he was smoking at the designated smoking area without facility staff supervision, carrying an open pack of cigarettes and a lighter on the side of his wheelchair. Resident 192 stated he kept the cigarettes and lighter on his own.
Review of Resident 192's clinical record indicated he was admitted on [DATE] with diagnoses including alcohol dependence, pain in the left hip, left ankle and joints of left foot. The admission nursing assessment, dated 3/28/22, indicated Resident 192 had short and long-term memory problems.
During a concurrent interview and record review, on 4/6/22 at 10:21 a.m., the DON reviewed Resident 192's clinical records and confirmed the admission nursing assessment, dated 3/28/22, indicated Resident 192 was a smoker. The DON confirmed the facility did not complete a smoking safety screening and care plan upon admission. She stated the smoking screening assessment and care plan should have been done upon admission.
During an interview on 4/6/22 at 10:36 a.m., with the DON, she stated that per the facility's policy and procedure, facility staff should have kept the cigarettes and lighter locked in the medication cart, or for independent smokers, the facility should have provided a locked drawer or container at bedside.
3. During a concurrent observation and interview on 4/4/22 at 9:03 a.m., Resident 193 stated he kept his own cigarettes and lighter inside his pocket when he smoked in the designated smoking area, and he kept the cigarettes and lighter in his bedside table drawer at night. Resident 193 stated there was no staff supervising him while he smoked.
During a concurrent interview and record review, on 4/6/22 at 11:08 a.m., the DON reviewed Resident 193's clinical record and confirmed the admission nursing assessment, dated 3/16/22, indicated Resident 193 was a smoker. The DON confirmed Resident 193's smoking safety was screened and smoking care plans were not initiated upon admission.
Review of the facility's policy, Smoking Policy, revised 2/2018, indicated licensed nurses, certified nursing assistants and interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) are responsible to monitor and evaluate residents for safety related to smoking .The IDT is responsible for evaluating safety risk and providing a safe designated smoking location, facility have specific smoking rules that are provided to residents and families at the time of admission. The IDT is responsible for evaluating safety risks and providing a safe designated smoking location .Staff will control the distribution of smoking material (cigarettes, cigars, tobacco, lighters) and for independent smokers that was assessed by the IDT, smoking materials should be locked in a drawer or container.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 24's Consultation Report, dated 3/1/22 through 3/8/22, indicated the resident had received quetiapine 200 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 24's Consultation Report, dated 3/1/22 through 3/8/22, indicated the resident had received quetiapine 200 milligrams (mg, unit of dose measurement) every 12 hours for bipolar disorder since 5/2021, Bupropion 100 mg every 12 hours since 3/2021, and clonazepam (used to control anxiety) 1 mg twice a day since 2021 for anxiety. The pharmacist (PH) recommended, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual .
Review of the above report indicated on 3/11/22, the physician responded to the recommendation with his initials.The consultation report did not indicate a detailed rationale for the continuation of the medication. Rationale: The space provided for the physician to document a rationale was left blank.
During a concurrent interview and record review on 4/8/22 at 12:26 p.m., with the PH, she reviewed Resident 24's clinical record and stated the report indicated the physician could accept or decline the recommendation, and the report indicated the physician responded to the recommendation on 3/11/22. The box to decline the recommendation was not checked and if checking that box indicated, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below.
During an interview on 4/7/22 at 2:10 p.m., the DON acknowledged the physician did not document a rationale describing he declined the recommendation, and the physician should have documented rationales on the space provided.
Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated GDR should be attempted twice in the first year of admit or use (within two quarters separated by one month in between) unless clinically contraindicated.
Based on interview and record review, the facility failed to act on reports from the pharmacist for two of five residents (Residents 11 and 24) when:
1. For Resident 11, the physician did not document patient-specific rationales describing the reason for gradual dose reductions (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) are clinically contraindicated for the use of quetiapine (antipsychotic medication used to treat mental or mood disorders) and sertraline (medication used to treat depression) and the facility did not act on the pharmacist's Medication Regimen Review (MRR) recommendation to perform an Abnormal Involuntary Movement Scale (AIMS) assessment; and,
2. For Resident 24, the physician did not document patient-specific rationales describing the reason GDRs are clinically contraindicated for the use of quetiapine and bupropion (medication for the treatment of depression).
These failures had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects.
Findings:
1.a. Review of Resident 11's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function) and psychosis (a mental disorder that may include deletions and hallucinations).
Review of Resident 11's physician orders indicated he had an order, dated 1/7/21 for quetiapine 25 milligrams (mg, unit of measurement) at bedtime for depression, visual hallucinations, paranoid delusions, and agitation. A GDR was attempted when Resident 11 had a physician order, dated 2/2/21 quetiapine 25 mg 0.5 tablet (12.5 mg) for visual hallucinations, paranoid delusions, agitation. There was no documentation that indicated another GDR of quetiapine was attempted in the first year of Resident 11's admission.
Review of Resident 11's Consultation Report, dated 2/10/22 indicated that Resident 11 was due for assessment for GDR and to consider reducing the dose of quetiapine. The report indicated the physician could accept or decline the recommendation.
Review of the above report indicated the physician responded to the recommendation on 2/18/22. The box to decline the recommendation was checked. Checking that box indicated, I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below. (NOTE: Please check option #1 or #2 AND provide patient-specific rationale on the lines below. The physician checked option #2. Checking that box indicated, The resident's target symptoms returned or worsened after the most recent GDR attempt . Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual: The space provided for the physician to document a rationale was left blank.
During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) acknowledged the physician did not document a rationale describing why a GDR attempt was clinically contraindicated.
b. Review of Resident 11's physician orders indicated he had an order dated 1/8/21 for sertraline 50 mg every day for depression, sadness, and angry outbursts. A GDR was attempted when Resident 11 had a physician order, dated 7/17/21 sertraline 25 mg every day for depression. There was no documentation that indicated another GDR of sertraline was attempted in the first year of Resident 11's admission.
Review of Resident 11's Consultation Report, dated 10/25/21 indicated the resident receives quetipine 25 mg at bedtime, sertaline 25 mg once daily for depression, and PRN Haldol (antipsychotic medication). The pharmacist recommended, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual . The report indicated the physician could accept or decline the recommendation.
Review of the above report indicated the physician responded to the recommendation on 11/1/21. The box to decline the recommendation was checked. Checking that box indicated, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The space provided for the physician to document a rationale was left blank.
During an interview on 4/7/22 at 1:36 p.m., the DON acknowledged the physician did not document a rationale describing he declined the recommendation.
Review of the facility's policy, Psychotropic Medication Management, dated 11/2017 indicated GDR should be attempted twice in the first year of admit or use (within two quarters separated by one month in between) unless clinically contraindicated.
c. Review of Resident 11's Consultation Report (MRR), dated 2/8/21, indicated the pharmacist recommended, Please monitor for involuntary movements now and at least every [six] months or per facility protocol.
Review of Resident 11's Consultation Report, dated 3/2/21 indicated that the nurse noted (acknowledged) the recommendation to perform AIMS but it could not be located under assessments.
Review of Resident 11's Assessments indicated he had an AIMS assessment completed on 3/2/21.
During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) acknowledged that the February 2021 pharmacy recommendation was missed.
Review of the facility's policy, Medication Regimen Review, dated 11/2016 indicated the facility should encourage the director of nursing to act upon the recommendations contained in the MRR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 34's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depres...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 34's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (feeling nervous, restless or tense).
Review of Resident 34's physician order indicated Citalopram 10 milligrams (mg, a metric unit of mass) every day for depression/anxiety, with the start date of 3/5/22, and Notriptyline 25 mg at bedtime for depression/anxiety, with the start date of 3/4/22. There were no evidence the resident was monitored for the manifested behaviors and the side effects of two medications.
During an interview with the director of nursing (DON) on 4/8/22 at 12:42 p.m., she reviewed Resident 34's clinical record and confirmed there were no evidence the resident was monitored for the manifested behaviors of depression/anxiety and the side effects of citalopram and notriptyline.
3. Review of Resident 242's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression.
Review of Resident 242's physician order, dated 4/2/22, indicated an order of Notriptyline 10 mg at bedtime for depression. There was no documented evidence the resident was monitored for the side effects of Notriptyline.
During an interview with the DON on 4/8/22 at 12:38 p.m., she reviewed Resident 242's clinical record and confirmed there were no monitoring for the side effects of notriptyline. DON stated Resident 242 should be monitored for the notriptyline side effects.
Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated the facility observe, report the behaviors and monitor the medication side effects and document them in the Electronic Health Record (EHR).
Based on interview and record review, the facility failed to ensure three of five residents (Residents 11, 34, and 242) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications.
1. For Resident 11, there was no documented clinical rationale by the physician to extend an as-needed (PRN) Ativan (medication used to treat anxiety) order beyond 14 days, there was no documented evaluation by the physician to renew a PRN Ativan order, and the Abnormal Involuntary Movement Scale (AIMS) assessment was not completed timely;
2. For Resident 34, there was no side effect monitoring and behavior monitoring for the use of citalopram (medication used to treat depression) and nortriptyline (medication used to treat depression); and
3. For Resident 242, there was no side effect monitoring for the use of nortriptyline.
These failures had the potential to result in lack of adequate monitoring and for the residents to receive unnecessary medications.
Findings:
1. a. Review of Resident 11's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function) and psychosis (a mental disorder that may include delusions and hallucinations).
Review of Resident 11's physician orders indicated he had the following Ativan orders:
1) Ativan 0.5 mg every six hours PRN for agitation, dated 2/12/22 until 3/6/22;
2) Ativan 0.5 mg every six hours PRN for agitation, dated 3/6/22 until 3/20/22; and
3) Ativan 0.5 mg every six hours PRN for agitation, screaming, and hitting others, dated 3/28/22 until 4/11/22.
Review of Resident 11's progress notes indicated there was no documented clinical rationale by the physician to extend his PRN Ativan order beyond 14 days and there was no documented evaluation by the physician to renew his PRN Ativan orders
During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) confirmed there was no documented rationale each time Resident 11's PRN Ativan order was renewed.
During an interview on 4/8/22 at 12:43 p.m., the pharmacist (PH) stated the doctor should have a documented rationale if a PRN psychotropic order is extended beyond 14 days and the doctor should have a documented reason to write a new PRN psychotropic order.
Review of the facility's policy, Psychotropic Medication Management, dated 11/2017, indicated clinically necessary PRN psychotropic drug orders are limited to 14 days. If the prescribing practitioner determines a need for continued PRN use beyond the original 14 days, it is accompanied by supporting documentation in the electronic health record including rationale for continued use and duration.
b. Review of Resident 11's physician orders indicated the following:
1) Resident 11 was admitted with an order for quetiapine 25 milligrams (mg, unit of measurement) at bedtime on 1/7/21;
2) Resident 11's quetiapine order was reduced to 12.5 mg at bedtime on 2/2/21; and
3) Resident 11's quetiapine order was increased to 25 mg at bedtime on 8/7/21.
Review of Resident 11's care plan for psychosis, revised 4/6/22, indicated to complete AIMS assessment every six months and with each increase in dose of antipsychotics.
Review of Resident 11's Assessments indicated he had an AIMS assessment completed on 3/2/21, 10/15/21, and 3/9/22.
During an interview on 4/7/22 at 1:36 p.m., the director of nursing (DON) stated there was no AIMS assessment done for Resident 11 upon admission. The DON also stated the AIMS assessment should be completed every 6 months and with increase in the dose of antipsychotic. The DON acknowledged the 10/15/21 AIMS assessment was one month late. The DON also acknowledged there was no AIMS done when Resident 11's quetiapine order was increased.
Review of the facility's policy, Psychotropic Medication Management, dated 11/2017 indicated if antipsychotic medications are used, an AIMS assessment will be completed upon admission, at the onset of a new order, every six months, and if medication dose is increased.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when:
1. Undated foo...
Read full inspector narrative →
Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when:
1. Undated food, over used by date food, expired food, and dented cans were found in the freezer and on the shelves in the kitchen;
2. [NAME] F (CK F) used his bare hand to pick up a lid which dropped inside the sliced peach can; and,
3. [NAME] G (CK G) and the dietary manager (DM) did not sanitize the thermometer before checking the temperature of the sliced peach and sugar free lemonade.
These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 40 residents eating at the facility.
Findings:
1. On 4/4/22 at 8:50 a.m., during an observation of the freezer, in the dry food storage room, with the registered dietician (RD), one bag of frozen french fries, with the use-by date (the last date recommended for the use of the product) of 3/11/22, and one bag of undated frozen tortillas were found.
On 4/4/22 at 9 a.m., during an observation in the dry food storage room and in the cooking area, with the RD and the dietary manager (DM), the following were observed:
a. One dented can of mushroom pieces and stems, one dented can sliced peaches and two dented cans of coconut milk were on the shelves
b. Six (6) caramel sauces with a use-by date of 3/21/22
c. One basic cheddar cheese sauce with a use-by date of 3/16/22
d. Five (5) cans of olives cans with a use-by date of 8/31/21
e. One can pizza sauce with basil with a use-by date of 2/3/22
f. One cornbread mix with an expiration date of 9/30/21
g. One box of 280 bags containing 1.2 oz coffee without a use-by date and/or an expiration date
h. One brown rice bin with a use-by date of 3/28/22
i. Ten (10) coffee bags without a use-by date and/or an expiration date
j. One brown sugar container with a use-by date of 4/3/22
k. One container of tarragon leaves with a use-by date of 3/19/22
l. One bottle of mushroom flavored dark soy sauce with a expiration date of 12/25/21
m. One ground nutmeg container with a use-by date of 3/12/22
n. One bottle of blended sesame oil with a use-by date of 1/23/22
During an interview with the DM on 04/06/22 at 3:15 p.m., she stated dented cans, undated food, over use-by date food, and expired food should have not been on the shelves and should have been discarded.
Review of the facility's policy, Food Safety in Receiving and Storage, dated 2/2009, indicated Food will be inspected when it is delivered to the facility and prior to storage for signs of contamination. Examples of signs of contamination include the following: a. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks . Expiration dates and use-by dates will be checked to assure the dates are within acceptable parameters.
2. During an observation on 4/06/22 at 11:05 a.m., CK F opened a can of sliced peaches, the lid was dropped down into the can and with his bare hands, CK F picked up the lid in the can.
During a concurrent interview with CK F, he stated he should have not picked up the lid with his bare hand.
Review of the facility's policy, Safe Food Handling, dated 9/2017, indicated Use utensils to handle food or wear disposable gloves when it is necessary to handle food directly with your hands.
3. During an observation on 4/06/22 at 11:10 a.m., CK G calibrated the thermometer in ice water and without sanitizing the thermometer, poked the thermometer into the canned peaches to check the temperature.
During a concurrent interview with CK G, she stated she should have sanitized the thermometer before checking the temperature of the canned peaches.
During an observation on 4/6/22 at 11:50 a.m., the DM removed thermometer cap, and dipped it into the cup of sugar free lemonade to check its temperature without sanitizing the thermometer.
During a concurrent interview with the DM, she stated she should sanitize the thermometer before checking the temperature of the sugar free lemonade.
Review of the facility's policy, Safe Food Handling, dated 9/2017, indicated Each new operation shall begin with food contact surfaces and utensils that are clean and have been sanitized.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented wh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:
1. The facility stored clean pillows and residents' clothing next to the dirty laundry;
2. Blood pressure stand machine had five medication cups and one Opti foam dressing together with a blood pressure cuff;
3. The dressing of Resident 26's peripherally inserted central catheter (PICC, a long, flexible thin tube that is put into a vein in the upper arm) was not changed weekly;
4. Certified nursing assistant H (CNA H) carried dirty linen in the hallway out of a resident's room; and,
5. Facility staff did not wear full personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering a resident's room who was on COVID-19 quarantine.
These failures had the potential to result in the spread of infection throughout the facility.
Findings:
1. During a concurrent observation and interview on 4/7/22 at 12:50 p.m. with laundry services staff (LS) and central supply staff (CS), in the facility's laundry room, the bin marked dirty containing the facility's dirty laundry, was next to the clean laundry bin containing residents' clean clothing, and both bins were uncovered. In the corner, multiple pillows for residents were observed uncovered. LS stated she was not sure if they should be stored like that.
During an interview on 4/8/22 at 1:30 p.m., the DON and IP stated clean and dirty laundry should not be next to each other.
During a review of the facility's policy Laundry Services dated 2012, it indicated Separating clean from dirty in the laundry: Dirty linen should be clearly separated from areas where clean linen is handled.
2. During an initial tour of the facility on 4/4/22 at 9:58 a.m., there were five medication cups and one Opti foam dressing were placed together in the basket with a blood pressure cuff of a blood pressure machine stand.
During a concurrent observation and interview on 4/4/22 at 9:59 a.m., Registered Nurse A (RN A) confirmed the above observation and stated it should not be there due to infection control issue and contamination.
3. Review of Resident 26's admission Record indicated she was admitted to the facility on [DATE].
During an observation, on 4/4/22 at 11 a.m., Resident 26 had a PICC line on her left upper arm. The dressing covering the PICC line was dated 3/24/22.
During an observation and interview with registered nurse C (RN C) on 4/4/22 at 11:38 a.m., RN C confirmed Resident 26's PICC dressing was changed on 3/24/22 and it should had been changed weekly on 3/31/22.
During an interview on 4/8/22 at 12:34 p.m., the director of nursing (DON) stated PICC dressing should have been changed every week.
Review of the facility's policy, Peripherally Inserted Central Catheter (PICC) Dressing Change, dated 8/15/08, indicated Dressing changes using transparent dressings are performed at least weekly .
4. During an observation on 4/4/22 at 11:29 a.m., certified nursing assistant H (CNA H) was making the bed for Resident 242. CNA H carried dirty linen from Resident 242's bed, walked out of Resident 242's room, walked through the hallway to place the dirty linen into the dirty linen storage room.
During a concurrent interview with CNA H, she stated she should have a linen hamper in front of Resident 242's room so she could throw the dirty linen in the hamper. CNA H stated she should not carry Resident 242's dirty linen out of the resident's room.
During an interview with the infection preventionist (IP), on 4/8/22 at 1:05 p.m., she stated CNA H should have not carried dirty linen out of the resident's room and in the hallway.
Review of the facility's undated Lesson Plan, Infection Control - Linen Handling, indicated Soiled linen should be immediately placed in a linen hamper .
5. During an observation, on 4/5/22 at 10:10 a.m., the dietary manager (DM) entered Resident 296's room without eye protection, N95 mask, or gown. Signs outside the door indicated Resident 296 was on precautions.
During an interview on 4/5/22, at 10:30 a.m., the DM confirmed she should wear appropriate PPE upon entering the room for residents with precautions.
During an observation on 4/6/22, at 9:16 a.m., the DON entered Resident 296's room with a gown and N95 mask, but no eye protection. Registered nurse E (RN E) entered the room with a gown, but with a surgical mask and no eye protection.
During an interview on 4/5/22 at 10:03 a.m., registered nurse C (RN C) stated Resident 296 was admitted on [DATE] and was on precaution. She confimed everyone entering a room with precaution signs needed to wear appropriate PPE until it is cleared by infection control.
During an interview on 4/6/22, at 1:18 p.m., with the DON regarding a policy for new admission quarantine, she confirmed Resident 296 a new admission who was not fully vaccinated against COVID-19, should be put on precautions. The DON stated all personnel entering the room should wear appropriate PPE.
During an interview and record review on 4/7/22 at 1:34 p.m., the director of staff development (DSD) and back-up infection preventionist (IP) confirmed new admissions who were not fully vaccinated against COVID-19 should be quarantined, all staff were provided in-services regarding quarantine policy, and staff should use the full PPE when entering these residents' rooms.
Review of facility policy, COVID-19 Management & Mitigation Policy, updated 2/25/2022, indicated, New admissions that are not up to date with all recommended COVID-19 vaccine doses (including booster, if eligible) should be tested and quarantined (in single rooms or a separate observation area i.e., yellow-zone) for at least 7 days from the date of admission until results of testing sample obtained between days 5 and 7. Those testing negative can be released from quarantine . Staff caring for them should use full PPE includes gowns, gloves, eye protection, and N95 or higher-level respirator.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 40% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Palo Alto Sub-Acute And Rehabilitation Center's CMS Rating?
CMS assigns PALO ALTO SUB-ACUTE AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Palo Alto Sub-Acute And Rehabilitation Center Staffed?
CMS rates PALO ALTO SUB-ACUTE AND REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Palo Alto Sub-Acute And Rehabilitation Center?
State health inspectors documented 38 deficiencies at PALO ALTO SUB-ACUTE AND REHABILITATION CENTER during 2022 to 2025. These included: 36 with potential for harm and 2 minor or isolated issues.
Who Owns and Operates Palo Alto Sub-Acute And Rehabilitation Center?
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COVENANT CARE, a chain that manages multiple nursing homes. With 66 certified beds and approximately 57 residents (about 86% occupancy), it is a smaller facility located in PALO ALTO, California.
How Does Palo Alto Sub-Acute And Rehabilitation Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, PALO ALTO SUB-ACUTE AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.2, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Palo Alto Sub-Acute And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Palo Alto Sub-Acute And Rehabilitation Center Safe?
Based on CMS inspection data, PALO ALTO SUB-ACUTE AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Palo Alto Sub-Acute And Rehabilitation Center Stick Around?
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER has a staff turnover rate of 40%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Palo Alto Sub-Acute And Rehabilitation Center Ever Fined?
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Palo Alto Sub-Acute And Rehabilitation Center on Any Federal Watch List?
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.