Asbury Park Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 2257 Fair Oaks Boulevard, Sacramento, California 95825
- CMS Provider Number
- 555673
- Inspections on file
- 52
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Asbury Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as flies were observed in the rooms of two residents whose sliding doors were open and lacked screens. Staff and maintenance confirmed that most sliding doors in the building had no screens, and the DON acknowledged concerns about flies, expecting staff to keep doors closed until screens were installed. Pest control service records were reviewed, but the fly issue persisted.
A resident with muscle atrophy and incontinence was left in a soiled brief for an extended period, despite expressing discomfort and using the call light. Staff, including CNAs and the DON, acknowledged the importance of timely changing to prevent dignity issues, but failed to act promptly. The facility's dignity policy, which emphasizes prompt response to toileting needs, was not followed.
Three residents were not protected from peer abuse, including physical altercations and racial slurs. One resident with cognitive impairment was slapped by another, a second was punched in the thigh by a peer, and a third experienced emotional distress after being subjected to racial and verbal abuse by a roommate. Staff and documentation confirmed these incidents, and the affected residents had varying degrees of cognitive and physical impairment.
The facility did not follow the planned menu for therapeutic diets, affecting 128 residents. Twenty residents on CCHO diets received margarine, two residents on CCHO and renal diets did not receive the correct meal components, and nine residents on puree diets did not receive the puree wheat roll. Additionally, all residents missed the parsley garnish. The Director of Dietary Services acknowledged the issues, and the Registered Dietitian emphasized the need to adhere to the menu.
The facility failed to ensure food safety, with an unclean ice machine, improperly stored kitchenware, a missing air gap in a prep sink, incorrect dishwashing procedures, and staff without proper beard restraints. These issues posed a risk of food contamination for all residents.
The facility failed to securely close one of two garbage dumpsters outside, leaving gaps that could attract pests. The Dietary Assistant Manager confirmed the issue, and the Registered Dietitian emphasized the need for tightly closed lids to prevent pest problems. Facility policy and the FDA Food Code require secure, tight-fitting lids for waste receptacles.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). Additionally, medication accountability was lacking during shift changes, with missing signatures on controlled drug sign-in/sign-out sheets. The facility also did not have an efficient system to document and secure emergency medications (E-Kit), and medications were not secured safely, with retrievable crushed and partially crushed medications found in multiple medication carts.
The facility failed to ensure three residents were free from unnecessary psychotropic medication use. A resident received Seroquel without non-pharmacological interventions for bipolar disorder. Another resident was given Seroquel without adequate indication, and staff confirmed no symptoms of schizophrenia. A third resident's Lorazepam order did not match the behavior being monitored, with no documented non-drug interventions. Facility policies requiring non-pharmacological approaches were not followed.
A facility failed to maintain a medication error rate below 5%, with errors observed during medication passes for three residents. Errors included incorrect dosing of diclofenac gel, failure to prime an insulin pen, incorrect measurement of ClearLax, and administering glipizide without a meal. These actions were not in accordance with prescriber's orders or manufacturer's specifications.
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Medications were not stored according to manufacturer specifications, and discontinued medications were not disposed of properly. Medication carts were disorganized, with controlled medications not stored securely and some medications lacking resident-specific labels. Resident 81, with multiple diagnoses, was found with an albuterol inhaler at the bedside without authorization to self-administer, highlighting further issues with medication management.
The facility failed to have written agreements with dialysis clinics for three residents receiving dialysis treatment. Despite multiple attempts to secure contracts, the facility was unable to provide valid agreements, leading to potential accountability issues in the dialysis services provided.
The facility failed to maintain effective infection control practices, as evidenced by improper storage of nasal cannulas and nebulizer equipment for several residents, and environmental cleanliness issues in the laundry room. Staff confirmed these deficiencies, acknowledging the potential for contamination and infection risk.
The facility failed to maintain the laundry room in a safe and operable condition, with observations of wet floors and corroded, leaking pipes. The Director of Environmental Services confirmed the issue, noting that repairs were pending. The Infection Preventionist also observed moisture and lint on the ground, contrary to facility expectations.
A facility failed to obtain informed consents from the authorized representative for a resident with severe cognitive impairment. Consents for treatment, POLST, and psychotropic medication were signed by individuals not listed as the responsible party, such as the resident's daughter-in-law and son. Staff interviews confirmed the discrepancy, acknowledging that the responsible party's name was on the resident's chart, and the expectation was for them to sign the consents. Facility policies emphasized obtaining consents from the resident representative, which was not adhered to, leading to the deficiency.
The facility failed to secure confidential resident health data when a computer on Medication Cart 2A was left unattended with a resident profile open, facing the hallway. A nurse acknowledged the breach, and the DON confirmed the expectation for staff to protect resident records. The facility's policy requires only authorized access to electronic medical records.
A facility failed to provide written notice of bed hold to a resident's responsible party when the resident, who was severely cognitively impaired, was transferred to a hospital. Despite attempts to contact the RP, no written notice was documented, violating the facility's policy requiring notification within 24 hours of transfer.
A resident did not receive their prescribed Citalopram for eight days due to a failure in the facility's admission process to carry over the medication order. The resident, who was cognitively intact and had a history of depression, experienced withdrawal symptoms and reported these to the staff, but the medication was still not administered. The admitting nurse and DON confirmed the oversight, which was contrary to the facility's medication reconciliation policy.
A resident with diabetes and chronic kidney disease did not receive necessary podiatry care, resulting in long and thick toenails. Despite a physician's order for podiatry care every two months, the resident had not seen a podiatrist since admission. Internal communication failures led to the oversight, as the need for toenail clipping was noted but not addressed. Facility policy requires diabetic residents to be referred to podiatry services, but there was no evidence of rescheduled appointments.
A facility failed to ensure proper communication with a dialysis clinic regarding a resident's anemia management. The resident, with ESRD and anemia, was supposed to receive Epoetin Alfa at dialysis, but records showed it was not administered. Instead, the resident received Mircera, a different medication, without the facility's knowledge, impacting their ability to monitor treatment effectiveness.
A facility failed to ensure a consultant pharmacist conducted a Medication Regimen Review (MRR) for a resident with Major Depressive Disorder, schizophrenia, and diabetes. The resident had multiple orders for Seroquel, but the CP did not complete an MRR as required by the facility's policy. This oversight was confirmed by the Pharmacy Manager and the Director of Nursing, highlighting a lapse in monitoring the resident's medication regimen.
The facility failed to meet the dietary needs of two residents. A resident with dysphagia was served broccoli, which he dislikes, and another resident on a mechanical soft diet did not receive his preferred gelato. Staff confirmed these oversights, and the facility's policy requires honoring food preferences and substituting disliked items.
Two residents in the facility were found with inaccessible call lights, potentially leading to unmet needs and delayed staff response. One resident, with moderate cognitive impairment and requiring substantial assistance, had their call light on the floor, while another resident, cognitively intact but dependent on staff, had their call light pinned between the bed rail and bed frame. The DON confirmed the issue, which contradicts the facility's policy requiring accessible call lights.
A resident with multiple medical conditions left an LTC facility unsupervised without a physician's order for a Leave of Absence (LOA). The resident, who required assistance for mobility, used a rideshare service to visit his son. Facility staff, including a new CNA, failed to follow the LOA policy, leading to the resident's unsupervised departure. Miscommunication and misunderstanding of discharge procedures contributed to the incident.
A facility failed to maintain an effective IPCP for 134 residents, as staff did not wear required PPE during catheter care for a resident on ESP. PPE was not available outside the rooms of three residents on ESP, increasing cross-contamination risk. The LN was unfamiliar with PPE requirements, and the DON acknowledged the infection risk. Facility policies and CDC guidelines stress PPE availability and staff training for effective EBP implementation.
The facility failed to respond promptly to call lights, compromising the dignity and care of three residents. A resident's family reported long waits for assistance, leading to incontinence. Another resident expressed dissatisfaction with delayed responses, risking spills. Observations showed a resident left waiting over an hour for help, visibly distressed. Staff interviews revealed non-compliance with timely response policies, acknowledged by the DON.
The facility failed to report the results of a 5-day investigation within the required timeframe after an altercation between two residents, where one resident scratched the other. The facility did not provide evidence to the CDPH that a summary of the investigation and corrective actions were submitted on time. The DON confirmed the delay in submission.
The facility failed to ensure safe evacuation routes, as they were cluttered with carts, commodes, linen bins, and garbage bins. A resident demonstrated the issue by attempting to navigate an emergency exit in a wheelchair, finding it obstructed. The DON confirmed the clutter and non-functional alarms, acknowledging the routes should have been clear and bins covered for infection control.
Failure to Maintain Effective Pest Control Program Due to Missing Door Screens
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in residents' rooms. Observations and interviews revealed that two residents had flies in their rooms, with one resident confirming that flies were present all the time. Both rooms had sliding doors that were open and lacked screens, which was confirmed by a CNA. The Director of Maintenance acknowledged that 14 out of 16 sliding doors in the building did not have screening doors and confirmed an ongoing fly issue. The Director of Nursing also confirmed concerns regarding flies and expected staff to keep sliding doors closed until screens could be installed. A review of pest control service invoices for the preceding months showed ongoing pest control efforts, but these were not effective in preventing the fly issue. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents, but the lack of screens on most sliding doors and the presence of flies in resident rooms demonstrated a failure to meet this standard.
Failure to Maintain Resident Dignity Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, who was admitted in the summer of 2016 with a diagnosis of muscle atrophy and wasting, by leaving him in a soiled brief for an extended period. The resident, who was totally dependent on staff for toileting, was observed to have a strong odor coming from his room, indicating he was soiled. Despite the resident's call light being on and his verbal expression of discomfort and upset due to being soiled, staff members, including CNAs and an Infection Preventionist, did not promptly address his needs. The resident remained in a soiled brief for an extended period, which was confirmed by multiple staff members, including a CNA and the Director of Nursing, who acknowledged the importance of timely changing to prevent dignity issues and skin problems. Interviews with staff, including CNAs, a Licensed Nurse, and the Director of Nursing, revealed a lack of timely response to the resident's needs, with staff indicating that they would inform the primary CNA or wait for another staff member to address the issue. The facility's policy on dignity, which prohibits demeaning practices and emphasizes the importance of promptly responding to residents' requests for toileting assistance, was not adhered to in this instance. The Social Service Director confirmed that the resident was alert and oriented, capable of expressing his needs, yet his requests were not promptly met, compromising his dignity and comfort.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect three residents from abuse by their peers, resulting in incidents of physical and verbal abuse. In one case, a resident with major depressive disorder and schizophrenia, but who was cognitively intact, slapped another resident with severe cognitive impairment after an altercation involving personal belongings. Staff documentation and interviews confirmed that the physical contact occurred before staff could intervene, and the resident who was slapped was unable to recall the incident due to cognitive impairment. In another incident, a cognitively intact resident with a history of cellulitis and diabetes was observed by staff grabbing and punching the thigh of a severely cognitively impaired resident with end-stage renal disease and chronic respiratory failure. The staff member witnessed the physical aggression and noted that the aggressor had exhibited similar behaviors with a previous roommate during the same shift. The resident who was struck verbally threatened staff during an interview and did not wish to continue the conversation. A third incident involved a resident with difficulty walking and muscle weakness who experienced racial and verbal abuse from a roommate, leading to emotional distress and a panic attack. Staff and family members confirmed that the resident was subjected to racial slurs and mocking language, resulting in the resident being moved to another room and requiring medication for anxiety. The facility's policy prohibits all forms of abuse, including verbal and physical, but these incidents demonstrate that residents were not adequately protected from peer abuse.
Failure to Follow Therapeutic Diet Menus
Penalty
Summary
The facility failed to adhere to the planned menu for therapeutic diets during a lunch meal distribution, affecting 128 residents. Specifically, 20 residents on controlled carbohydrate (CCHO) diets received margarine, which was not part of their prescribed diet. Two residents on CCHO and renal diets did not receive the correct meal components, such as baked fish and wheat rolls, as indicated on the menu. Additionally, nine residents on puree diets did not receive the puree wheat roll as specified. Furthermore, all 128 residents did not receive the parsley garnish that was supposed to accompany their meals. These deficiencies were identified through observation, interviews, and record reviews. The Director of Dietary Services acknowledged the issues, attributing the lack of parsley garnish to a failure to order it. The Registered Dietitian confirmed awareness of the issues and emphasized the importance of following the menu/spreadsheet. The facility's policy mandates that menus meet the nutritional needs of residents and comply with the diet manual, which was not followed in this instance.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety in several areas, as observed during a survey. The ice machine was found to be unclean, with significant dark brown and yellow substances identified as calcium buildups on the evaporator unit. The maintenance department was responsible for monthly cleaning, while an outside vendor was tasked with deep cleaning every three months. However, despite a recent service, the machine was still dirty, indicating a lapse in the cleaning process. Additionally, various kitchenware items were improperly stored while still wet and with food particles, contrary to the facility's policy that requires them to be clean and air-dried before storage. The facility also failed to maintain proper sanitation standards in other areas. An air gap was missing from the fruit and vegetable prep sink, which is necessary to prevent backflow and contamination. Furthermore, a dietary aide incorrectly verbalized the manual dishwashing process, stating that dishes were immersed in sanitizer for only two seconds instead of the required 60 seconds. This discrepancy highlights a lack of proper training or adherence to established procedures, which could compromise the sanitation of kitchenware. Lastly, two kitchen staff members were observed without proper beard restraints, using medical masks instead. This was against the facility's dress code policy, which mandates beard restraints to prevent hair from contacting food and clean equipment. These deficiencies collectively posed a risk of food contamination, potentially affecting all 128 residents who rely on the facility's kitchen for their meals.
Improperly Secured Garbage Dumpster
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not securely closing one of two garbage dumpsters located outside the facility. During an observation and interview with the Dietary Assistant Manager, it was noted that the lids of one dumpster were not securely covering the bin, leaving gaps on both sides. The Dietary Assistant Manager confirmed that the lids lacked integrity and agreed that this was unacceptable. In a subsequent interview, the Registered Dietitian stated that the dumpster lids should be tightly closed without any openings or gaps to prevent pest and rodent issues. A review of the facility's policy indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and the trash collection area must be kept clean to avoid attracting vermin and rodents. The 2022 FDA Food Code also requires outside receptacles containing food residue to have tight-fitting lids, doors, or covers.
Controlled Medication Accountability and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications were signed out of the Controlled Drug Record (CDR) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. For instance, Resident 69 had tramadol signed out on two occasions, but the MAR did not reflect administration. Similarly, Resident 58 had discrepancies between the CDR and MAR for oxycodone, and Resident 65 had tramadol signed out without corresponding MAR documentation. The Director of Nursing (DON) confirmed that nursing staff were expected to document administered doses on both the MAR and CDR. The facility also failed to maintain medication accountability during shift changes, as evidenced by missing signatures on controlled drug sign-in/sign-out sheets for two medication carts. Nine signatures were missing for Medication Cart 2A, and five were missing for Medication Cart 1C. Licensed Nurses 7 and 8 acknowledged the missing signatures and confirmed the expectation for both outgoing and incoming nurses to sign the sheets during shift changes. The facility's policy required controlled substances to be reconciled at the end of each shift, with both nurses determining the count together. Additionally, the facility did not have an efficient system to document and secure emergency medications (E-Kit). An inspection revealed discrepancies in the E-kit log, with missing documentation for removed oxycodone tablets and Ativan vials. The DON stated that nursing staff were expected to ensure accurate E-kit logs and request replacements promptly. Furthermore, medications were not secured safely, as multiple medication carts contained retrievable crushed and partially crushed medications, including controlled substances. The DON confirmed that medications should be rendered irretrievable before disposal, as per the facility's policy.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use. Resident 7 was administered Seroquel for bipolar disorder without the implementation of non-pharmacological interventions to attempt a gradual dose reduction or discontinuation of the medication. The Director of Nursing confirmed that the care plans did not include non-drug interventions, despite the facility's policy requiring such measures to minimize medication use. Resident 128 was given Seroquel without adequate indication for its use. The resident's medical records showed a series of orders for Seroquel with varying dosages and indications, none of which were supported by documented evidence of hallucinations or delusions. Interviews with staff and the resident revealed that the resident did not exhibit symptoms of schizophrenia, and the resident expressed concern over a misdiagnosis. The facility's policy stated that antipsychotic medications should only be used when clinically indicated, which was not adhered to in this case. Resident 25's behavior order for Lorazepam did not match the behavior being monitored, and there was no documented evidence of non-pharmacological interventions being used when behaviors occurred. The resident's care plan and medication administration records showed inconsistencies in the behavior being monitored and the behavior for which the medication was prescribed. Interviews with staff indicated that non-drug interventions were not consistently documented, despite the facility's policy requiring such documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 12.5% during a medication pass. This was based on four medication errors out of 32 opportunities observed for three residents. The errors included incorrect dosing and administration of medications, which were not in accordance with the prescriber's orders or manufacturer's specifications. For Resident 110, a Licensed Nurse (LN 2) was observed preparing diclofenac gel but measured only 2 grams instead of the prescribed 4 grams. This discrepancy was confirmed during a review of the resident's medical record and an interview with LN 2. The facility's policy required medications to be administered as per the prescriber's orders, which was not followed in this instance. Resident 104 experienced two medication errors. LN 2 failed to prime an insulin aspart pen before administration and incorrectly measured ClearLax, not filling it to the indicated line for the correct dose. These errors were acknowledged by LN 2 during interviews. Additionally, Resident 12 was given glipizide without a meal, contrary to the manufacturer's instructions, which could lead to hypoglycemia. LN 3, who administered the medication, was unsure of the timing considerations for glipizide. The facility's policy emphasized the importance of administering medications in a safe and timely manner, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. During an inspection of medication carts and storage rooms, it was observed that medications were not stored according to manufacturer specifications. For instance, a bottle of acidophilus was not refrigerated as required, and an acetic acid irrigation solution was opened without an open or discard date. Additionally, discontinued medications were not disposed of properly, as evidenced by an opened box of aformoterol left on a shelf instead of being placed in the drug disposal bin. Medication carts were found to be disorganized and not securely locked when unattended. Controlled medications, such as phenobarbital, were not stored in the designated controlled drug drawer, and medications like clonidine patches were comingled with oral medications. Furthermore, several inhalers and nasal sprays lacked resident-specific labels, increasing the risk of incorrect administration. Expired medications, such as labetalol, were also found in the carts, and some medications were stored without proper labeling or dating, such as EvenCare G3 test strips and budesonide inhalation solution. Resident 81's case highlighted additional issues with medication management. The resident, who had multiple diagnoses including COPD and moderate cognitive impairment, was found with an albuterol inhaler at the bedside without an assessment or order to self-administer. Despite staff acknowledging the risk of overmedication and the need for the inhaler to be stored in the med cart, it remained at the bedside. The facility's policies indicated that medications should not be stored at the bedside unless authorized, which was not the case for Resident 81.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources, specifically dialysis services, had written agreements in place. This deficiency was identified for three residents who were receiving dialysis treatment without existing agreements with the dialysis clinics. The absence of these agreements could lead to a lack of responsibility and accountability in the dialysis services provided to the residents. Resident 36 was admitted with end-stage renal disease and required dialysis. The care plan and physician orders indicated the need for dialysis, but during interviews, the Administrator and Director of Transportation Services admitted that there was no current contract with the dialysis clinic. The agreement provided was outdated and lacked specific details, and the facility was unable to produce a valid contract during the survey. Similarly, Resident 15, who was severely cognitively impaired and dependent on dialysis, was also receiving dialysis services without a contract in place. Despite multiple attempts by the Director of Transportation Services to obtain a contract from the dialysis clinic, the facility was unable to secure one. Resident 51, also dependent on dialysis, was in a similar situation, with the facility still waiting for a contract from the dialysis center at the time of the survey.
Infection Control Deficiencies in Equipment Handling and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper handling and storage of medical equipment and environmental cleanliness issues. Resident 36's nasal cannula was repeatedly observed on the floor in their room, both when the resident was present and absent, despite the facility's policy requiring such equipment to be stored in a protective bag. Similarly, Resident 46's nasal cannula was also found on the floor, contrary to the facility's infection control expectations. Interviews with staff confirmed these observations and acknowledged the potential for contamination. Environmental issues were also noted in the facility's laundry room, where dust particles were observed on vents above the clean linen area, and moisture and dust were present at the back of the washers. The Director of Environmental Services confirmed these observations, acknowledging that the dust could contaminate clean linens and that the moisture and lint on the ground were not acceptable. The facility's policies require maintenance personnel to follow infection control precautions, which were not adhered to in this instance. Resident 71's nebulizer tubing and mask were improperly stored in a drawer without a protective bag and were not labeled with the date of change, as required by the facility's policy. The oxygen concentrator humidifier bottle was also not labeled with the date of change. The Infection Preventionist and Director of Nursing confirmed these deficiencies, noting that the improper storage and lack of labeling put the resident at risk for infection. Resident 3's oxygen tubing was similarly found on the floor, with the nasal cannula not properly stored, which was confirmed by a Certified Nursing Assistant and the Director of Nursing.
Deficiency in Laundry Room Maintenance
Penalty
Summary
The facility failed to maintain the building and equipment in a functional and operable manner, as evidenced by the condition of the laundry room. During an observation and interview, it was noted that the floor at the back of the washer was wet, and the pipes were dirty, corroded, and leaking. One pipe was observed to be corroded with a greenish color, and the leakage was confirmed to be coming from this pipe. The Director of Environmental Services acknowledged the issue and mentioned that a company had been contacted for repairs, but no confirmation on the repair timeline was available. The Infection Preventionist also confirmed the presence of moisture and lint on the ground, which was not in line with the facility's expectations. A review of the facility's maintenance policy indicated that maintenance service should ensure all areas of the building, grounds, and equipment are safe and operable at all times.
Failure to Obtain Informed Consent from Authorized Representative
Penalty
Summary
The facility failed to obtain informed consents from the authorized resident representative for a resident, identified as Resident 97, who was admitted with major depressive disorder and dementia. The resident's records indicated severe cognitive impairment, and the spouse was designated as the responsible party (RP). However, consents for treatment, Physician Orders for Life-Sustaining Treatment (POLST), and psychotropic medication were signed by individuals not listed as the RP, such as the resident's daughter-in-law and son. Interviews with facility staff, including a licensed nurse, the Assistant Director of Staff Development, and the Nurse Supervisor, revealed that verbal consents were obtained from individuals other than the RP, contrary to the facility's policy. The staff acknowledged that the RP's name was on the resident's chart, and the expectation was for the RP to sign the consents. The Director of Nursing and Nurse Consultant confirmed the discrepancy and stated that the RP should have been contacted for consent, as the RP has the decision-making capacity for the resident's care. The facility's policies and procedures emphasized the importance of obtaining consents from the resident representative, especially when the resident is deemed incompetent. The policies outlined that the RP should be informed of the care, risks, and benefits of treatments, and that informed consent for psychotropic medications should be verified and documented. The failure to adhere to these policies resulted in the deficiency, as the consents were not obtained from the designated RP, potentially compromising the resident's rights and care decisions.
Failure to Secure Resident Health Data
Penalty
Summary
The facility failed to protect and secure confidential resident health data and records for a census of 132 residents. During an observation, a computer on Medication Cart 2A was left unattended with a resident profile open, facing the resident hallway. This incident occurred in hallway 2A and was observed at 4:30 p.m. on January 7, 2025. Licensed Nurse 7 acknowledged the computer was left unlocked and unattended, making resident records accessible to unauthorized individuals, which he recognized as a violation of confidentiality. The Director of Nursing confirmed that nursing staff are expected to ensure resident records are not visible to unauthorized staff. The facility's policy, dated March 2014, states that only authorized persons with a password and user ID should access the electronic medical records system.
Failure to Notify Resident's Representative of Bed Hold
Penalty
Summary
The facility failed to provide written notice of bed hold to the responsible party (RP) of a resident when the resident was transferred to a hospital. The resident, who was severely cognitively impaired and unable to make their own decisions, was transferred to an acute care hospital for further evaluation due to hypotension and an infected catheter site. Despite attempts to contact the RP, the call went to voicemail, and no written notice of the bed hold was documented in the resident's clinical record for this transfer. The facility's policy requires that all residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours in the case of an emergency. However, the Director of Nursing acknowledged that the Transfer and Bed Hold Form was not completed, and the RP was not notified of the bed hold for the resident's transfer to the hospital. This oversight was identified during a review of the resident's clinical records and interviews with facility staff.
Failure to Administer Psychotropic Medication Upon Admission
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following their admission policy and procedure, resulting in a psychotropic medication order not being carried over for a resident upon admission. This oversight led to the resident not receiving their prescribed Citalopram, a medication for depression, for eight days. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of depression and was on Citalopram 20 mg daily as per their hospital discharge orders. However, the medication was not documented in the facility's records upon admission, and the resident experienced withdrawal symptoms as a result. The resident reported symptoms such as shaking, crying, nausea, dizziness, and muscle pain, which they attributed to the lack of their antidepressant medication. Despite informing the facility staff multiple times, the medication was not administered. The admitting nurse and the Director of Nursing confirmed that the medication order was missed during the admission process, which involved reviewing and reconciling hospital discharge orders with the admitting physician. The facility's policy on medication reconciliation, which aims to prevent medication errors and ensure accurate communication of medication orders, was not followed in this instance.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot care for a resident, identified as Resident 51, who had long and thick toenails. Resident 51, who was admitted with type 2 diabetes mellitus and diabetic chronic kidney disease, had not received podiatry care since admission, despite a physician's order for podiatry care every two months. The resident, who was cognitively intact, reported not having seen a podiatrist since admission, and observations confirmed the toenails were long and thick. Certified Nursing Assistant 2 noted the need for toenail clipping about a month prior, but the issue was not addressed. The facility's internal communication failed to ensure the resident received podiatry care. The Assistant Director of Staff Development stated that concerns noted in shower sheets should be directed to the responsible person, but the Social Services Director did not receive any notification regarding the resident's toenails. The Nurse Supervisor confirmed the need for podiatry care upon observing the resident's toenails. The facility's policy indicated that diabetic residents should not have their toenails trimmed by staff, and they should be referred to podiatry services if necessary. However, there was no documented evidence that the resident's podiatry appointments were rescheduled after being missed.
Failure in Communication of Anemia Management for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration between the facility and the dialysis clinic regarding the anemia management of a resident with end-stage renal disease (ESRD) and anemia. The resident was admitted with diagnoses including ESRD and anemia, and their care plan required the administration of Epoetin Alfa at the dialysis center. However, the facility's Medication Administration Records (MARs) indicated that the medication was signed off as given at dialysis, despite the dialysis communication sheets showing that the resident did not receive Epoetin Alfa during dialysis. Instead, the resident was receiving Mircera, a different anemia medication, every two weeks, which was not communicated to the facility. The dialysis nurse confirmed that Epoetin Alfa had been discontinued and replaced with Mircera. The Director of Nursing and Nurse Consultant acknowledged the lack of communication regarding the medication change, which resulted in the facility being unaware of the resident's current anemia management. This oversight decreased the facility's ability to monitor the medication's effectiveness and side effects, as outlined in their policies and procedures.
Failure to Conduct Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) conducted a Medication Regimen Review (MRR) for a resident, identified as Resident 128, who was admitted with diagnoses including Major Depressive Disorder, schizophrenia unspecified, and diabetes. The resident had several physician's orders for Seroquel, an antipsychotic medication, with varying dosages and indications for use. Despite these orders, the CP did not complete an MRR for Resident 128 in December 2024, as confirmed by both the Pharmacy Manager and the Director of Nursing during interviews and record reviews. The facility's policy and procedure, dated May 2019, clearly stated that the CP is responsible for performing an MRR for every resident receiving medication, particularly upon admission. However, the CP failed to adhere to this policy, resulting in inadequate monitoring of Resident 128's medication regimen. This oversight had the potential to impact the optimization of the resident's medications for the best possible health outcome, as the irregularities in the medication regimen were not identified or reported by the CP.
Failure to Accommodate Dietary Preferences and Requirements
Penalty
Summary
The facility failed to accommodate the special dietary requirements for two residents during a lunch observation. Resident 106, who has dysphagia, was served a puree meal that included broccoli, despite having a documented dislike for broccoli on his meal ticket. The Certified Nursing Assistant (CNA) confirmed the presence of broccoli and acknowledged that the resident did not want it. The Director of Nursing (DON) stated that staff are expected to review meal tickets and provide alternatives if a disliked food is served. Resident 108, who is on a mechanical soft diet, did not receive the gelato he preferred, as indicated on his meal ticket. The Assistant Director of Staff Development (ADSD) confirmed the absence of gelato on the meal tray and acknowledged that it should have been provided. The Director of Dietary Services (DDS) stated that resident preferences, as indicated on meal tickets, should be honored. The facility's policy on food preferences requires that dislikes be substituted with appropriate alternatives.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to potential unmet needs and delayed staff response. Resident 22, who was admitted with multiple diagnoses including generalized muscle weakness, had a moderate cognitive impairment and required substantial assistance for mobility. During an observation, Resident 22's call light was found on the floor, out of reach, despite the care plan indicating it should be within reach and monitored every two hours and as needed. Similarly, Resident 82, who was cognitively intact but dependent on staff for mobility, had their call light pinned between the bed rail and bed frame, making it inaccessible. Resident 82 expressed difficulty in calling for help due to the call light's position. The Director of Nursing confirmed the call lights were out of reach for both residents and stated that staff are expected to ensure call lights are accessible. The facility's policy requires each resident to have a means to call staff directly for assistance from their bed.
Resident Leaves Facility Unsupervised Due to LOA Policy Failure
Penalty
Summary
The facility failed to identify and prevent a resident from leaving the premises without staff awareness or a physician's order for a Leave of Absence (LOA). The resident, who was admitted with multiple diagnoses including acute osteomyelitis, pressure injury, and generalized muscle weakness, was cognitively intact but dependent on assistance for mobility. Despite these needs, the resident left the facility with an unidentified person and was not noticed missing until he returned on his own. The incident occurred when the resident, who was wheelchair-bound and required assistance for transfers, left the facility using a rideshare service to visit his son. The staff, including the assigned CNA and charge nurse, were unaware of the resident's departure due to a lack of communication and understanding of the LOA policy. The CNA, a new hire, mistakenly believed the person taking the resident was his son and did not verify the LOA process, leading to the resident's unsupervised exit. Interviews with facility staff and family members revealed confusion and miscommunication regarding the resident's whereabouts and the facility's discharge procedures. The Director of Nursing acknowledged the mistake, attributing it to the resident's room change and possible misunderstanding of being discharged. The facility's policy required a physician's order and proper documentation for LOA, which was not followed, resulting in the resident's unsupervised and potentially unsafe absence from the facility.
Inadequate PPE Use and Availability for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) for a census of 134 residents. Specifically, a staff member did not wear the required personal protective equipment (PPE) while providing catheter care for a resident on Enhanced Standard Precautions (ESP). Additionally, PPE was not readily available outside the rooms of three residents on ESP, increasing the risk of cross-contamination and potential infections among residents. The Licensed Nurse (LN) was unfamiliar with the necessary PPE requirements and did not use a gown or mask when changing the resident's indwelling urinary catheter. Observations and interviews revealed that PPE, including gowns, gloves, and masks, were not available outside the rooms of residents on ESP. The Director of Nursing (DON) acknowledged that not using required PPE could lead to infection. The facility's policy and procedure, as well as CDC guidelines, emphasize the importance of PPE availability and staff training for effective implementation of Enhanced Barrier Precautions. The deficiency was identified through a review of admission records, care plans, and physician's orders, highlighting the facility's failure to adhere to established infection control protocols.
Failure to Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to promote individual care and dignity by not responding to the call lights of three residents in a timely manner, leading to unmet needs and feelings of discomfort, embarrassment, and helplessness. Resident 1's family member reported that the resident, who was cognitively intact and had control over bladder and bowel functions, often had to wait over an hour for assistance, resulting in incontinence. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) and maintaining skin integrity, but these needs were not met due to delayed staff response. Resident 5, who was also cognitively intact, expressed dissatisfaction with the call light response, stating that he often had to wait 30 minutes or longer for help, which put him at risk of spilling his urine bottle. Observations confirmed that Resident 2, who had multiple diagnoses including difficulty walking and a recent shoulder dislocation, was left waiting for over an hour for assistance to use the commode. The resident was found standing in the doorway with wet incontinence briefs, visibly distressed and tearful, as staff walked by without offering help. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy on timely call light response. CNA 1 and LN 1 failed to assist Resident 2 promptly, and CNA 3, who was late for her shift, assumed other staff would attend to her residents. The DON acknowledged the issue and stated that call lights should be answered within 5-10 minutes, but observations showed that this standard was not met, resulting in compromised resident dignity and care.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of a 5-day investigation within the required timeframe for two residents involved in an altercation. Resident 1 scratched Resident 2 during an incident where Resident 2 approached Resident 1, exclaiming for her to leave, and swiped her hand towards Resident 1. In response, Resident 1 grabbed Resident 2's hand and swiped her own hand towards Resident 2's chest, resulting in three prominent scratch marks. The facility did not provide documented evidence to the California Department of Public Health (CDPH) that a summary of the investigation and appropriate corrective actions were submitted within 5 working days of the incident. The Director of Nursing (DON) confirmed during an interview that the 5-day follow-up investigation summary was not submitted within the required timeframe.
Cluttered Evacuation Routes and Non-Functional Alarms
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and the public by allowing evacuation routes to be cluttered with carts, bedside commodes, linen bins, and garbage bins. This deficiency was observed in a 139-bed facility and was highlighted by Resident 4, who expressed concerns about safety. Resident 4, admitted for aftercare of back surgery, demonstrated the issue by attempting to navigate an emergency exit route in his wheelchair. The route was obstructed by various items, making it impossible for him to pass through safely. Additionally, the emergency exit alarms did not sound when the doors were opened, further compromising safety. The Director of Nursing (DON) confirmed the presence of clutter and non-functional alarms during a concurrent observation and interview. The DON acknowledged that the evacuation routes should have been kept clear and that the garbage and linen bins should have been covered for infection control. A Certified Nurse Assistant (CNA) also confirmed that the bins were regularly placed outside the exit doors for staff use, despite knowing that these routes were designated for emergency use. The facility's policy stipulated that exits should be kept clear at all times to allow for rapid evacuation, which was not adhered to in this case.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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