Astoria Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 14040 Astoria Street, Sylmar, California 91342
- CMS Provider Number
- 056084
- Inspections on file
- 72
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at Astoria Healthcare Center during CMS and state inspections, most recent first.
A resident with diabetes, Alzheimer’s disease, and hypertension experienced a change of condition after an incident of physical aggression by another resident. A CNA reported the event to an LVN, who later completed a change-of-condition evaluation with the wrong date and shift for when the incident occurred. The LVN also documented incorrect times for when the MD and the resident’s family were notified, and could not recall the actual notification times. The evaluation was not completed and signed until two days after the event, contrary to facility policies requiring accurate, timely documentation and completion by the end of the assigned shift.
Surveyors found that three residents with existing sacral pressure ulcers or moderate risk for pressure ulcers, as indicated by Braden scores and MDS assessments, were not consistently turned and repositioned every two hours as required by their care plans. These residents had significant conditions such as Parkinson’s disease, diabetes, muscle weakness, and failure to thrive, and required maximal to moderate staff assistance or were fully dependent for rolling. Review of medical records with the TxN and confirmation by the DON showed no documentation that the ordered q2h repositioning was carried out, despite a facility pressure ulcer prevention policy requiring monitoring and documentation of prevention techniques.
A resident with Parkinson’s disease, type 2 DM, and a stage 4 sacral pressure ulcer experienced a change in condition with fever, SOB, and altered responsiveness and was transferred to a GACH, where the resident remained and was later discharged. Despite the resident no longer being in the facility, an LVN later documented that the resident was in bed, able to make needs known, free of SOB or acute distress, had received and tolerated all due meds, was kept clean and dry, and had specific vital signs recorded. During review, the DON confirmed the resident had already been transferred out at the time of this entry and that the documentation was inaccurate and not consistent with the facility’s nursing documentation policy.
A resident with end-stage renal disease and a history of removing her AV fistula dressing returned from hemodialysis and was not assessed or monitored as required by her care plan. Staff failed to inspect the access site or communicate the resident's return, resulting in the resident being found unresponsive and bleeding from the fistula site, leading to her death. Additionally, the facility did not promptly develop a care plan for another resident admitted to hospice, causing a delay in care planning.
A resident with ESRD, anemia, and a history of removing her own AV fistula dressing returned from hemodialysis and was not properly assessed or monitored by nursing staff. The RN did not inspect the access site or check vital signs, and no post-dialysis assessment was documented. The resident was later found unresponsive with severe bleeding from the AV fistula site and was pronounced deceased. Facility staff failed to follow established protocols for post-dialysis care and monitoring.
Nursing staff, including an RN and an LVN, did not receive orientation or in-service training on dialysis care or assessment, as confirmed by skills checklists, job descriptions, and staff interviews. The Director of Staff Development and the DON acknowledged that dialysis care was not part of the orientation process, and the facility's policy on staff competency was not followed for dialysis care. This resulted in staff lacking the necessary knowledge and skills to safely care for residents requiring dialysis.
The facility did not update its Facility Assessment Tool after a change of ownership and the implementation of electronic medical records, and failed to specify required staff training for dialysis care. The assessment continued to list the previous facility name and omitted details about electronic health information technology and dialysis competencies, resulting in outdated and incomplete documentation.
A resident's MDS assessment did not include a documented diagnosis of dementia, even though this was present in the primary physician's History and Physical. The MDS Coordinator relied on outdated admission records instead of reviewing current physician documentation, leading to an incomplete and inaccurate assessment.
A CNA did not change her gown after repositioning a resident with a gastrostomy and before draining another resident's Foley catheter, despite both requiring enhanced barrier precautions. This failure to follow infection control protocols was confirmed by the DON and had the potential for cross-contamination.
A resident with cognitive impairment was involved in an incident where a family member attempted to have them sign a bank authorization form. Staff intervened and identified the situation as potential financial abuse, but the required five-day investigation report was not completed in accordance with facility policy.
A resident with multiple chronic conditions fell after attempting to steady herself on a wheelchair that was not within reach. Although staff assessed the resident and completed required documentation, there was no evidence that an IDT meeting was held within the facility's required timeframe to investigate the fall and address its causes, as mandated by facility policy.
A resident with multiple chronic conditions experienced a fall, and the required Post-Fall Assessment & Investigation was not completed or documented in the medical record as mandated by facility policy. Staff confirmed the omission, and review of the electronic record showed the assessment template was left incomplete, resulting in an incomplete medical record.
The facility did not ensure proper documentation and follow-up regarding advance directives for three residents. One resident's chart lacked evidence that advance directive information was provided, another had no copy of a living will in the chart despite acknowledging its existence, and a third resident's request for assistance in formulating an advance directive was not adequately followed up or documented by social services staff.
Multiple residents experienced deficiencies in their living environment, including an inaccurate wall clock for a resident with dementia, broken and unrepaired blinds with makeshift cardboard coverings for another, a torn fall mat with equipment placed on it for a resident at high risk for falls, and cracked or missing wall sockets at the bedside of a resident with severe impairments. Staff and maintenance were aware of these issues, but they were not addressed in accordance with facility policy, resulting in an environment that was not safe, clean, or homelike.
Multiple residents were subjected to physical restraints, such as bed pad alarms, bolstered mattresses, beds placed against walls, and side rails, without proper restraint assessments, physician orders, informed consent, or care plans. Staff confirmed that these interventions were implemented without following required protocols, and necessary documentation was only completed after the deficiencies were identified.
Two residents were administered psychotropic medications without proper diagnoses or monitoring. One received Seroquel without a qualifying mental health diagnosis, and pharmacy recommendations to discontinue the drug were not followed up or documented. The resident was also not referred for psychiatric evaluation as required. Another resident was prescribed Remeron for poor appetite related to depression, but staff failed to implement required monitoring for both the targeted behavior and medication side effects, as confirmed by nursing and DON interviews.
The facility did not develop or implement comprehensive care plans for multiple residents, including those who smoked, received psychotropic or antianxiety medications, or required BiPAP therapy. This included missing care plans for smoking safety, medication monitoring, and respiratory equipment care, as well as incomplete documentation and communication among staff regarding residents' needs and interventions.
Three residents did not have their care plans updated to reflect current infection control precautions or the use of low air loss mattresses for pressure ulcer prevention. Staff interviews and observations confirmed that care plans were not revised after changes in physician orders or resident condition, and that mattress settings did not match residents' weights as required. These deficiencies led to potential miscommunication and delays in necessary care.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff repeatedly administered insulin in the same abdominal and arm locations over an extended period, a practice confirmed by both nursing staff and the DON through record review and interviews.
Multiple deficiencies were identified when medications and hazardous materials were left unattended in resident rooms, topical medications were applied without proper orders, and safety equipment such as floor mats and bed positions were not properly maintained. Staff failed to follow facility policies, resulting in increased risk of accidents and injuries for several residents with complex medical needs.
Several residents requiring respiratory support did not receive care in accordance with professional standards, as BiPAP masks and nebulizer equipment were improperly stored, not cleaned or documented per manufacturer and facility policy, and oxygen tubing and masks were not labeled with the date of last change. Staff interviews confirmed inconsistent cleaning and documentation practices, and facility policies for infection control and equipment maintenance were not followed.
Multiple deficiencies were identified in the facility's pharmaceutical services, including failure to administer medications as ordered, administration of expired medications, late medication administration, incomplete documentation of discarded medications, and improper supervision of medication administration. These issues involved several residents with various medical conditions and were confirmed through staff interviews, record reviews, and direct observation.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same areas, which was identified as a medication error according to facility policy and professional standards.
Surveyors found two unlabeled vials of meropenem in an IV cart after a resident's treatment was completed, and expired psyllium and docusate sodium in a medication cart. Nursing staff and leadership confirmed that these medications should have been discarded according to facility policy, but they remained accessible in storage areas.
Surveyors found that pureed mixed vegetables served to residents on a dysphagia puree diet were too thick and did not pass the required IDDSI Level 4 spoon tilt test. Staff did not consistently use the correct testing method to ensure proper food texture, and the Dietary Director confirmed the deficiency. Facility policies and recipes required these tests to be performed, but they were not followed, resulting in improper food consistency for all residents on a puree diet.
Surveyors found that kitchen staff failed to properly dispose of expired food, label and date various food items, and maintain sanitary storage and preparation practices. Observations included unlabeled produce, improperly stored thickener, mixed food items in bins, and unclean equipment. The dietary director confirmed that these actions did not follow facility policies for food safety and infection control.
Surveyors identified multiple failures in infection prevention and control, including lack of Enhanced Barrier Precautions for a resident with a history of VRE, improper disinfection of a cloth gait belt between residents, unclean supplement bottles on medication carts, staff not wearing or securing gowns during high-contact care, linen carts inadequately protected from dust, and improper storage and documentation of respiratory equipment. These deficiencies were confirmed through staff interviews, observations, and policy reviews.
Facility staff used the PT gym's therapy mat and surrounding area to store therapy equipment, broken items, and items awaiting disposal, making the space unavailable for resident therapy. The DOR and DON acknowledged that the cluttered environment prevented use of the therapy area for its intended purpose and did not meet expectations for a homelike, orderly setting.
Surveyors found that essential equipment was not maintained in safe working order, including a non-functional freezer light in the kitchen, a resident's bed controller with exposed wires, and cracked or missing wall sockets at the head of another resident's bed. Staff failed to report these hazards as required by facility policy, resulting in unsafe conditions for two residents with significant medical needs.
A CNA assisted a resident with severe cognitive impairment and total dependence for ADLs by standing over them during mealtime, rather than sitting at eye level as required by facility policy. Both the RN and DON confirmed that this practice did not uphold the resident's dignity, and facility policies specifically prohibit standing over residents while feeding.
A resident with multiple diagnoses, including depression and schizophrenia, was administered Remeron, a psychoactive medication, without documented informed consent from the resident or responsible party. Facility staff acknowledged the oversight, and the DON confirmed that informed consent should have been obtained prior to administration, as required by facility policy.
A resident with multiple medical and psychiatric conditions was allowed to self-administer medications left at the bedside by an LPN, despite a prior assessment indicating the resident was not a candidate for self-administration and without a new assessment or physician's order. Facility staff acknowledged that required procedures for assessing and authorizing self-administration were not followed, and medications were left unattended in the resident's room.
A resident with severe cognitive impairment, hemiplegia, and a high fall risk was found with their call light disconnected from the wall, despite requiring total assistance for daily activities. A CNA and the DON confirmed that staff are responsible for ensuring call lights are plugged in and functioning, in accordance with facility policy.
Two residents were admitted with significant medical needs—one requiring oxygen therapy for respiratory conditions and another prescribed an anticoagulant for blood clot prevention. Despite physician orders and facility policy requiring baseline care plans within 48 hours of admission, no such plans were developed or implemented for either resident, as confirmed by nursing staff. This resulted in a deficiency related to the timely provision of essential healthcare services.
A resident with bone and joint conditions did not have an orthopedic appointment scheduled as ordered by the physician, despite documented orders and facility policy requiring coordination between nursing and social services. Nursing staff did not complete or document the referral process, resulting in a delay of care.
Two residents at high risk for pressure ulcers did not have their low air loss mattresses set according to their actual weight, contrary to manufacturer instructions and facility policy. Staff and the DON confirmed the settings were incorrect, and that proper adjustment is necessary for pressure injury prevention.
A resident with decreased ROM in both upper extremities did not receive the ordered AAROM exercises to the left upper extremity during an RNA session, as only the right side was exercised. The RNA omitted the left side, believing the resident could move it independently, despite care plan and physician orders requiring AAROM to both sides. This failure was confirmed by staff interviews and review of facility policy.
Staff did not consistently follow protocols for labeling and handling enteral feeding equipment for two residents with gastrostomy tubes. Feeding formula and water flush bags were not labeled with required information such as time hung and rate of infusion, and a specialized valve was left uncapped and disconnected. Nursing staff and the DON confirmed these lapses, which did not comply with physician orders or facility policy.
A CNA did not receive an annual skills competency evaluation as required by facility policy, with the last evaluation occurring over a year prior. The DSD scheduled the next evaluation based on the hire date rather than the annual requirement, and the DON confirmed the evaluation was overdue. Facility policies mandate annual performance and competency reviews for all staff.
Two residents experienced medication errors when a nurse administered an incorrect dose of docusate sodium to one resident and another nurse prepared to give expired docusate sodium to a second resident. These actions resulted in a medication error rate above the acceptable threshold, as staff failed to follow physician orders and did not check medication expiration dates as required by facility policy.
A resident with a right humeral neck fracture did not receive a timely CT scan after it was ordered by the orthopedic physician. The facility delayed requesting authorization for the scan by a month, which led to the cancellation of a follow-up orthopedic appointment and a significant delay in diagnostic imaging. Staff interviews confirmed the delay was due to late submission of the authorization request, contrary to facility policy requiring prompt processing of diagnostic orders.
Kitchen staff were not routinely trained or evaluated for competency in preparing pureed foods for residents on a dysphagia puree diet, resulting in pureed mixed vegetables being served at an improper consistency that did not pass required IDDSI testing. The cook relied on subjective methods rather than the mandated spoon-tilt test, and the facility's competency checklist did not cover necessary IDDSI Level 4 testing procedures. The Dietary Director confirmed that the puree did not meet standards and should have been adjusted before service.
A resident with muscle wasting, atrophy, and a right humeral neck fracture did not receive occupational therapy (OT) at the frequency specified in their care plan and physician orders. Although the plan required OT five times a week, documentation showed the resident received fewer sessions in several weeks, with no explanation for the missed treatments. The Director of Rehabilitation confirmed the deficiency and lack of documentation for the missed OT sessions.
The facility failed to ensure timely completion of OT documentation for a resident, with progress notes and discharge summaries being signed well after the required period. Additionally, an LVN inaccurately documented the time of medication administration in the MAR, recording medications as given during the scheduled pass when they were actually administered later. These actions resulted in inaccurate and delayed clinical records, contrary to facility policy.
A resident with a UTI was initially prescribed ciprofloxacin, which was discontinued and replaced with Keflex after lab results showed resistance. The Antibiotic Log was not updated to reflect the change, incorrectly showing a full course of ciprofloxacin and omitting the Keflex prescription. Staff interviews and policy review confirmed the log was incomplete and not maintained as required by the facility's antibiotic stewardship policy.
A resident with dementia, a history of falls, and a recent spinal fracture was care planned to have a bed alarm for fall prevention. Surveyors observed that the bed alarm was not functioning, and staff confirmed it was not in use, despite the care plan and family agreement. The alarm device was found disconnected and turned off, contrary to facility policy and the resident's individualized care plan.
A resident with a history of falls and multiple risk factors suffered a new fracture after staff failed to ensure her bed alarm was turned on and functioning, despite care plan instructions. Staff interviews and observations confirmed the alarm was not operational, and the resident's fall risk assessment was inaccurately scored as low risk, overlooking her medical history and recent fall. These failures resulted in inadequate supervision and interventions.
A resident with severe cognitive impairment was found with a swollen and painful right hand, later diagnosed as a fracture. The facility delayed reporting the injury of unknown origin to the SSA and Ombudsman, contrary to its policy requiring notification within 24 hours of the initial observation. Staff interviews revealed a misunderstanding of the reporting timeline, as the report was made only after X-ray confirmation of the fracture.
A resident with dementia and other conditions received acetaminophen before a physician's order was documented, leading to inaccurate medical records. The DON confirmed the discrepancy, highlighting a failure to adhere to the facility's documentation policy.
A facility failed to maintain a resident's medical record privacy when an LVN left an EHR open and unattended. The resident, with conditions including liver cell carcinoma and diabetes, required assistance with daily activities. The LVN admitted the risk of unauthorized access, and the ADON confirmed the need for securing the computer, as per HIPAA training policies.
Inaccurate and Delayed Change-of-Condition Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate, complete, and timely medical record for one resident who experienced a change of condition related to an incident of physical aggression by another resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, and essential hypertension, and had severely impaired cognitive skills for daily decision-making per the most recent MDS. A CNA reported that another resident attempted to hit this resident on the evening of 3/9/2026, and an LVN responded to the incident. The LVN later created a Change of Condition (COC) Evaluation but documented the COC as occurring on 3/10/2026 during the night shift instead of on 3/9/2026 during the 3 p.m. to 11 p.m. shift when the incident actually occurred. The COC Evaluation also contained inaccurate information regarding the timing of notifications to the resident’s attending physician and family member. The form indicated that the physician was notified at 9:20 p.m. and the family member at 9:15 p.m. on 3/10/2026, while the LVN stated that both were notified after midnight on 3/10/2026 but could not recall the exact times. The LVN acknowledged that the COC Evaluation was inaccurate. The Assistant DON confirmed that the resident’s change in condition occurred on 3/9/2026, that the COC Evaluation was not completed and signed until 3/11/2026, and that facility policy required documentation of the correct date and time of the incident and notifications, with nursing documentation to be completed by the end of the assigned shift. These findings showed that the facility did not follow its own policies on change of condition notification and nursing documentation, resulting in inaccurate and untimely entries in the resident’s medical record.
Failure to Reposition Residents at Risk for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards by not ensuring that three residents at moderate risk for pressure ulcers were turned and repositioned as care planned. One resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had a Braden score of 13 indicating moderate risk. The resident’s MDS showed moderately impaired cognition and a need for maximal assistance with rolling. The resident’s care plan, initiated shortly after admission, required assistance with turning and repositioning at least every two hours, but the treatment nurse and the DON both confirmed there was no documented evidence that this turning and repositioning occurred every two hours as ordered. Another resident was admitted with a stage 4 sacral pressure ulcer, muscle weakness, and adult failure to thrive, and had a Braden score of 13, also indicating moderate risk. This resident’s MDS showed severely impaired cognitive skills and total dependence on staff for rolling to either side. The interdisciplinary wound management care plan directed staff to reposition the resident every two hours or as often as necessary. During record review with the treatment nurse, it was determined there was no documented evidence that the resident was turned and repositioned every two hours, despite the care plan intervention and the resident’s dependence on staff for mobility. A third resident, admitted with type 2 diabetes mellitus, muscle weakness, and essential hypertension, had a Braden score of 14, indicating moderate risk, and required moderate assistance with rolling according to the MDS. This resident also had a sacrococcygeal pressure ulcer and an interdisciplinary wound management care plan that required repositioning every two hours or as often as indicated. The treatment nurse and the DON confirmed there was no documented evidence that this resident was turned and repositioned every two hours. The facility’s pressure ulcer prevention policy required nursing staff to monitor interventions for effectiveness and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques weekly, but the lack of documentation of turning and repositioning for all three residents demonstrated that these interventions were not implemented as required.
Inaccurate Nursing Documentation Entered After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with accepted professional standards for one resident. The resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had moderately impaired cognitive skills for daily decision-making per the MDS. A Change in Condition evaluation documented that the resident developed fever, shortness of breath, and a sudden change in level of consciousness or responsiveness. Progress notes show that on 12/10/2025 at 10:10 a.m., the resident was transferred to a general acute care hospital and did not return, ultimately being discharged from the hospital. Despite the resident’s transfer and non-return, a progress note dated 12/13/2025 was entered by an LVN documenting that she received the resident resting in bed, able to make needs known, being monitored for fever, congestion, and lethargy, with no shortness of breath or acute distress, no pain, all medications given and tolerated, and that the resident was kept clean and dry with call light within reach. The note also included specific vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) as if the resident were present in the facility. During interview and concurrent record review, the DON confirmed that the resident had been transferred out on 12/10/2025, did not return, and that the LVN’s 12/13/2025 documentation was inaccurate and not in accordance with the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate documentation of resident status and care given.
Failure to Implement Hemodialysis Care Plan and Timely Hospice Care Planning
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease who required hemodialysis and had a left upper arm arteriovenous (AV) fistula. The resident had a documented history of removing her pressure dressing prematurely after dialysis, resulting in previous bleeding episodes. Despite care plan interventions specifying that the dressing should remain in place for at least four hours post-dialysis and that the access site should be monitored for bleeding, redness, swelling, and pain upon return from dialysis, staff did not perform or document a post-dialysis assessment or direct inspection of the AV fistula site after the resident returned from treatment. The resident was also on Eliquis, an anticoagulant, further increasing her risk for bleeding. On the day of the incident, the resident returned from hemodialysis and was assisted to her room by an RN, who did not visually inspect the AV fistula site or check vital signs, assuming the site was not bleeding because the clothing was not wet. The RN did not inform other staff of the resident's return, and both the assigned LVN and CNA were on lunch breaks and unaware of the resident's status. Approximately 30 minutes later, the CNA discovered the resident unresponsive and actively bleeding from the AV fistula site, with the pressure dressing removed and blood present on the bed and floor. Emergency services were called, but the resident was pronounced deceased shortly after their arrival. Interviews and record reviews confirmed that the required post-dialysis assessment was not completed, and there was no documentation of monitoring or care provided to the AV fistula site upon the resident's return. The care plan interventions related to hemodialysis and AV fistula monitoring were not implemented, and staff failed to communicate and coordinate care as required. Additionally, the facility failed to promptly develop and implement a person-centered care plan for another resident admitted to hospice, resulting in a delay in care planning.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with assigned nursing staff, review of policy and procedure on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis. Failures related to post-dialysis assessment, monitoring, communication, and documentation were identified.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their dialysis access sites.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1.
- The DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9.
- The DON and DSD provided in-service training to nursing staff regarding care planning, with emphasis on: a) Implementation of residents' individualized hemodialysis care plans; b) Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment; c) Comprehensive assessment and monitoring of residents by LVNs or RNs following dialysis treatment.
- The DON provided a one on one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident.
Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
Failure to Ensure Nursing Staff Competency in Dialysis Care and Assessment
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care for residents requiring dialysis. Specifically, two of five sampled staff, including a registered nurse and a licensed vocational nurse, did not receive orientation or in-service training on dialysis care, assessment, or site evaluation. Review of their annual skills checklists and job descriptions revealed no documentation of dialysis-related competencies, and interviews with staff confirmed that dialysis care and assessment were not included in their orientation or ongoing training. The Director of Staff Development acknowledged that dialysis care, assessment, and training were not part of the orientation process and had not been provided to nursing staff, including CNAs, until recently. Staff interviews further revealed a lack of instruction on how to assess dialysis sites for thrill and bruit, as well as on procedures for managing residents before and after dialysis treatments. Some staff demonstrated confusion regarding the correct methods for assessing dialysis access sites, indicating gaps in knowledge and skills necessary for safe resident care. The Director of Nursing confirmed that while an in-service on dialysis care was provided in the past year, there was no formal class or consistent inclusion of dialysis care and assessment in new staff orientation. The facility's policy required nursing staff to demonstrate competencies based on resident needs, but this policy was not followed regarding dialysis care. The lack of documented training and competency checks for dialysis care and assessment had the potential to impact the safe provision of nursing care for residents undergoing dialysis.
Failure to Update Facility Assessment Following Ownership and Service Changes
Penalty
Summary
The facility failed to accurately update its Facility Assessment Tool following significant operational changes, including a change of ownership and transition to electronic medical records. The assessment continued to reflect the previous facility name after the approved change of ownership and did not document the adoption of electronic health information technology, despite the facility's transition from paper to electronic records. Additionally, while the assessment listed dialysis as a service provided, it did not specify the necessary staff training or competencies required for dialysis care. These omissions were confirmed during interviews with the Administrator and Director of Nursing, who acknowledged that the Facility Assessment should have been updated to reflect these changes and ensure accurate information regarding services and staff competencies. The facility's policy requires annual and as-needed updates to the Facility Assessment to ensure resources and staff competencies align with resident needs, including during emergencies. However, the assessment was not updated to include the new facility name, the implementation of electronic medical records, or the specific training and competencies for dialysis care. This failure resulted in the Facility Assessment containing outdated and incomplete information, which could misinform staff and the public about the facility's capabilities and resources.
Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected all current medical diagnoses. Specifically, the MDS did not include a diagnosis of dementia, despite this being documented in the resident's History and Physical (H&P) by the primary physician. The MDS Coordinator acknowledged that during the assessment process, staff relied on the existing admission record rather than reviewing the most recent H&P for new or updated diagnoses. This omission was identified during a review of the resident's records and confirmed in interviews with both the MDS Coordinator and the Director of Nursing (DON). The DON stated that it is the responsibility of the MDS Coordinator to ensure that all diagnoses from the primary physician's notes are accurately reflected in the MDS and the resident's care plan. The facility's policy requires that the Resident Assessment Instrument (RAI) process includes comprehensive and up-to-date information about the resident's health status at the time of assessment. The failure to update the MDS with the dementia diagnosis resulted in an inaccurate assessment for the resident.
Failure to Change Gown Between Residents During Care Activities
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow infection control policies and procedures when providing care to two residents. After repositioning one resident who was severely cognitively impaired and dependent on staff for activities of daily living, CNA 1 washed her hands and changed gloves but did not change her gown before proceeding to drain the urinary catheter of another resident in the same room. The second resident had a diagnosis of osteomyelitis and acute kidney failure, required substantial assistance, and had physician orders for enhanced barrier precautions and continuous Foley catheter drainage. CNA 1 acknowledged during the observation that she did not change her gown as required to prevent contamination between residents. The Director of Nursing confirmed that CNA 1 did not follow the facility's infection control protocols, which require staff to change gowns between care activities for residents under isolation precautions. The facility's infection prevention and control policy, last reviewed in June 2025, mandates measures to prevent the development and transmission of infection in accordance with federal and state requirements. The failure to change gowns between residents had the potential to cause cross-contamination.
Failure to Timely Investigate and Report Alleged Financial Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of financial abuse involving a resident diagnosed with Alzheimer's Disease, major depressive disorder, and anxiety. The resident was noted to have the ability to understand and be understood, but could not make medical decisions. On the date of the incident, a staff member observed a male family member attempting to have the resident sign a 'Borrower Authorization' form to access the resident's bank information. The Social Services Director (SSD) intervened, questioned the family member, and was denied access to the document. The SSD determined that the resident lacked capacity to make such decisions and reported the incident as financial abuse on the same day. Despite recognizing the incident as potential financial abuse, the SSD did not complete the required five-day report, believing that submitting the SOC341 form was sufficient. The Director of Nursing (DON) later confirmed that the five-day report, which should have been submitted within five days of the incident, was not completed until much later. Facility policy required timely reporting and investigation of abuse allegations, but this protocol was not followed, resulting in a deficient practice.
Failure to Conduct Timely IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) meeting was conducted in a timely manner following a resident's fall, as required by the facility's own policy and procedure. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and type 2 diabetes, experienced a fall after attempting to steady herself on a wheelchair that was out of reach while exiting the bathroom. The resident's care plan identified her as having poor balance, an unsteady gait, and poor safety awareness, with interventions such as keeping the call light within reach and frequent visual checks. After the fall, staff physically assessed the resident and completed documentation, but there was no documented evidence that an IDT meeting occurred within the required 72-hour timeframe to investigate the incident and determine causative factors. Interviews with staff, including an LVN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that facility policy mandates an IDT meeting within 72 hours of a fall to review the event, conduct a root cause analysis, and implement interventions to prevent future incidents. However, the review of the resident's electronic medical record did not show that such a meeting took place after the fall. The facility's Fall Management Program policy specifically requires the IDT-Falls Committee to meet and document their findings and actions within this timeframe, but this protocol was not followed in this case.
Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented, as required by its own policy and procedure. After a resident experienced a fall, the required Post-Fall Assessment & Investigation was not completed or documented in the resident's medical record. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and diabetes mellitus type 2, reported falling while attempting to steady herself after leaving the bathroom. The fall was witnessed by her roommate, who sought staff assistance. Staff interviews confirmed that, although the facility's policy mandates a Post-Fall Assessment & Investigation following any resident fall, this documentation was not completed for the incident in question. Review of the resident's care plan and medical record showed that the Post-Fall Assessment & Investigation template was created in the electronic record but left incomplete. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that the assessment should have been completed by a registered nurse shortly after the incident, but it was not done. The facility's policy specifically requires this documentation to be maintained in the resident's medical record following a fall, and the failure to do so resulted in an incomplete record for the resident involved.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to show documented evidence that advance directives were discussed and appropriately managed for three sampled residents. For one resident with acute respiratory failure, pneumonia, and cerebral infarction, there was no Advance Directive Acknowledgement Form in the medical chart, despite the resident having intact cognition and the capacity to make decisions. Both the RN and Social Services Designee confirmed the absence of documentation, and the Social Services Designee admitted that although the family was spoken to, there was no proof that information about advance directives was provided. Another resident, admitted with multiple diagnoses including neuropathy and diabetes, had signed an Advance Directive Acknowledgement Form indicating the existence of a living will. However, the actual living will was not present in the resident's chart, and there was no documentation regarding its contents. The responsible Social Services staff member acknowledged forgetting to follow up and obtain a copy of the living will, which was necessary for staff to be aware of and honor the resident's wishes when the resident could no longer make decisions. A third resident, with diagnoses including congestive heart failure and urinary retention, had expressed interest in formulating an advance directive and requested assistance from the Ombudsman. Although the facility faxed a request to the Ombudsman, there was no documented follow-up or evidence in the medical record that assistance was provided or that the process was completed. The Social Services staff and Director both acknowledged that the lack of follow-up and documentation could result in delays or failure to honor the resident's wishes, as the process had been pending for over three months.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six sampled residents, as evidenced by multiple deficiencies observed during the survey. For one resident with dementia and other cognitive impairments, the wall clock at the bedside consistently displayed the incorrect time over several days. Staff interviews confirmed awareness of the issue, and facility policy required the clock to be accurate to assist with reality orientation for residents with cognitive deficits. The clock was not corrected in a timely manner, despite its importance for resident orientation. Another resident, who had decision-making capacity and was dependent on staff for several activities of daily living, experienced ongoing issues with broken vertical blinds in their room. The missing and fallen slats were left on the floor, and cardboard was taped to the window to block light, as reported by the resident and observed by staff. The resident expressed dissatisfaction with the situation, stating it had persisted for months. Staff interviews revealed that maintenance requests were not consistently made or followed up on, and the environment was not maintained in a homelike or dignified manner, as required by facility policy. A third resident, identified as high risk for falls and with severe cognitive impairment, was found to have a fall mat at the bedside that was torn and had a side table placed on top of it. Staff acknowledged that the mat should not be torn or have equipment placed on it, as this compromised its function and the homelike appearance of the room. Additionally, another resident with severe cognitive and physical impairments had wall sockets at the head of the bed that were cracked and missing covers. Staff and maintenance personnel confirmed these issues and stated that they should have been addressed immediately to maintain a safe and homelike environment. Facility policies reviewed required prompt maintenance and upkeep of resident rooms, but these were not followed in these instances.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple instances involving five residents. For one resident with a history of falls and severe cognitive impairment, the facility did not accurately complete the physical restraint assessment form to reflect the use of a bed pad alarm, despite having a physician's order and care plan for fall risk. The restraint assessment did not indicate the current type of restraint or the reason for its use, and the admissions nurse did not document whether less restrictive measures had been attempted prior to the application of the restraint. Another resident with dementia and a history of falls was found to be using a bolstered mattress without a current physician's order, informed consent, restraint assessment, or care plan after discharge from hospice care. The facility continued to use the bolstered mattress as a restraint without completing the necessary documentation or obtaining consent from the resident's representative. Staff interviews confirmed that the required assessments and documentation were only completed after the deficiency was identified. Additional deficiencies were observed for three other residents. Two residents had their beds placed against the wall, which staff acknowledged as a form of restraint that limited the residents' ability to exit the bed from one side. There were no physician's orders, informed consents, restraint assessments, or care plans for this intervention. Another resident had three side rails up and a side table blocking the open side of the bed, also without the required physician's order, informed consent, restraint assessment, or care plan. In all cases, staff interviews confirmed that these interventions were implemented without following the facility's policy and procedure for restraint use, which requires pre-restraining assessment, physician's order, informed consent, and care planning.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraint
Penalty
Summary
Two residents were not protected from unnecessary psychotropic medication use, resulting in chemical restraint. One resident was administered Seroquel daily for psychosis, despite lacking a diagnosis of schizophrenia, depression, or bipolar disorder, which are the only acceptable indications for this medication in elderly patients. The resident's records, including the face sheet, care plan, and Minimum Data Set, did not support the use of Seroquel, and a Preadmission Screening and Resident Review confirmed the absence of a serious mental illness. The medication was continued after hospital readmission without proper verification, and the facility's own policies required antipsychotic medications to be used only when necessary for specific, documented conditions. A pharmacy recommendation to discontinue Seroquel due to lack of appropriate diagnosis was not followed up in a timely manner. The recommendation was not signed or dated by the attending physician, and there was no documentation of agreement or alternative action. Additionally, a psychiatrist consultation, as noted in the physician's progress notes, was not initiated after the resident's readmission, and the resident was not included on the list for psychiatric evaluation. Facility staff interviews confirmed that the necessary follow-up actions were not taken, and the resident continued to receive Seroquel unnecessarily. Another resident was prescribed Remeron for depression manifested by poor appetite, but there were no orders for monitoring the specific behavior (poor appetite) or for monitoring potential side effects of the medication. Nursing staff acknowledged missing the required monitoring orders, and the DON confirmed that such monitoring is necessary to determine the effectiveness of the medication and to identify any adverse effects. Facility policies required that psychotropic medications be supported by documented rationale, administered at correct doses and duration, and with adequate monitoring, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents in key areas, as observed through record reviews, interviews, and direct observation. For one resident with a history of urinary tract infection, end stage renal disease, and schizophrenia, the facility did not create a care plan addressing the resident's smoking habits, despite the resident being assessed for smoking and requiring supervision and a smoking apron. Staff interviews confirmed that the absence of a smoking care plan could result in staff being unaware of the resident's needs and the necessary safety precautions. Another resident with chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder was prescribed Remeron for depression and poor appetite. However, no care plan was developed to address the use of this medication, including monitoring for side effects and meal intake. Staff acknowledged that the care plan should have been created when the medication was ordered, and the lack of such a plan meant that staff would not know what interventions were in place or how to monitor the resident's response to the medication. Additionally, a resident with acute respiratory failure, COPD, and congestive heart failure was prescribed BiPAP therapy at night, but the care plan did not specify the cleaning schedule or duration of therapy. Observations revealed inconsistent cleaning and documentation practices for the BiPAP equipment, and staff interviews confirmed that the care plan lacked necessary details for proper care and infection control. Furthermore, two residents receiving antianxiety and psychotropic medications did not have care plans addressing the use of these drugs, their potential side effects, or monitoring requirements. Staff interviews indicated that the absence of these care plans could lead to unrecognized adverse effects and inconsistent care.
Failure to Revise Care Plans for Infection Control and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for three residents, resulting in deficiencies related to infection control and pressure ulcer prevention. For one resident with a history of vancomycin-resistant enterococcus (VRE) in the urine, the care plan was not updated to reflect the discontinuation of contact isolation and the implementation of enhanced barrier precautions (EBP) as ordered by the physician. Both the Infection Preventionist and the Director of Nursing confirmed that the care plan should have been revised to indicate the current precaution status, but it was not, which could create confusion among staff regarding the appropriate infection control measures. Two other residents, both at high risk for developing pressure ulcers, had physician orders for the use of low air loss mattresses (LALM) to preserve skin integrity. However, their care plans were not updated to include the LALM as an intervention for pressure ulcer prevention. Observations revealed that the LALM settings for both residents did not match their current weights, as required by manufacturer specifications and facility policy. Nursing staff acknowledged that the care plans should have been revised to reflect the use of LALM and that the settings should be adjusted according to the residents' weights to prevent skin breakdown. The facility's policy requires that care plans be developed and implemented within seven days of the comprehensive assessment and be reviewed and updated when there are changes in the resident's condition or interventions. Despite this, the care plans for these residents were not revised to reflect current orders and interventions, leading to potential miscommunication among staff and a delay in necessary care and services. The deficiencies were identified through record reviews, staff interviews, and direct observations.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were prescribed subcutaneous insulin, by not rotating the injection sites as required by physician orders, facility policy, and manufacturer guidelines. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, insulin was repeatedly administered in the same abdominal quadrants over several weeks, despite clear orders and documentation requiring site rotation. Both the registered nurse and the director of nursing confirmed that the administration sites were not rotated, acknowledging that this was not in compliance with professional standards or the physician's orders. Another resident, who was alert and oriented but had a history of diabetes and hemiplegia, also received insulin injections at the same sites on the abdomen and arm over a period of months. Medication administration records showed multiple instances where the injection sites were not rotated, contrary to the facility's policy and the manufacturer's prescribing information. Nursing staff confirmed that the sites were not rotated as required, and the director of nursing acknowledged that this practice did not follow established guidelines. Facility policy on insulin administration, as well as the manufacturer's guidelines for both types of insulin used, specifically require rotation of injection sites to prevent complications. The failure to rotate sites was confirmed through interviews with nursing staff and review of medical records, which documented repeated use of the same injection locations for both residents. This practice was not in accordance with professional standards, physician orders, or the facility's own procedures.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. In several instances, medications were left unattended and accessible in residents' shared rooms, despite assessments indicating that these residents were not safe candidates for self-administration. For example, one resident had a cup containing multiple medications left on the bedside table by an LVN, who stated that the resident preferred to take medications one at a time. However, there was no physician's order or assessment supporting self-administration, and facility policy required direct observation during medication administration. Additionally, topical medications such as A&D ointment were left at the bedside and on the floor, and were applied by a CNA without a physician's order, contrary to facility policy and scope of practice requirements. Hazardous materials were also found in resident rooms without proper supervision. One resident had a large aerosol can of bug spray stored on a dresser next to food items. Staff who observed the spray did not remove it, despite facility policy prohibiting hazardous chemicals in resident rooms and the potential for confused or wandering residents to misuse such items. The Director of Nursing confirmed that the presence of bug spray in a resident's room was not in accordance with facility policy and posed a risk to residents. Environmental hazards were present in the form of improper use and maintenance of safety equipment. Several residents who were at risk for falls had floor mats intended to prevent injury, but these mats were obstructed by furniture or medical equipment, such as visitor chairs and overbed tables, which compromised their effectiveness. In one case, a resident's fall mat had a significant tear, and in others, beds were not maintained in the lowest position as required by care plans. Additionally, a resident was found using a heating pad without a physician's order, and another had a bed remote with frayed wires, both of which posed risks of injury or electrocution. These deficiencies were observed during interviews and record reviews, and staff acknowledged that such practices were not in line with facility policies and procedures.
Deficient Respiratory Care and Infection Control for Residents Requiring Oxygen and BiPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services in accordance with professional standards of practice for four residents requiring respiratory support. For one resident with acute respiratory failure, COPD, and CHF, the BiPAP mask was observed hanging on the wheelchair brake handle, not stored in a manner free from contamination. The BiPAP mask and nebulizer were stored together in an unlabelled plastic bag, lacking the resident's name and the date of last change. Staff interviews revealed inconsistent cleaning practices for the BiPAP mask, with some staff using alcohol wipes and others using soap and water, but without documentation of cleaning or adherence to the manufacturer's instructions. The care plan did not specify cleaning frequency or duration of BiPAP therapy, and administration records lacked consistent documentation of BiPAP use and cleaning, contrary to facility policy and manufacturer guidelines. For three other residents with diagnoses including acute respiratory failure, pneumonia, and COPD, oxygen was administered via nasal cannula or nebulizer, but the tubing and masks were not labeled with the date of last change. In some cases, nebulizer equipment was observed stored in a plastic bag with an outdated date, and in others, the tubing was not dated at all. Staff interviews confirmed that respiratory tubing and masks should be labeled and changed at regular intervals, as per facility policy, but this was not consistently done. The facility's policies required disposable supplies to be changed every 5 to 10 days and labeled with the date of last change, but these procedures were not followed. The Director of Nursing and other staff acknowledged that failure to clean and document respiratory equipment care, as well as improper storage and labeling, could lead to bacterial accumulation and potential infection. Facility policies and manufacturer instructions were reviewed, all of which emphasized the importance of regular cleaning, proper storage, and documentation of respiratory care. However, observations and staff interviews demonstrated that these standards were not consistently met for the residents reviewed, resulting in deficiencies in respiratory care and infection control practices.
Failure to Ensure Accurate Medication Administration and Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. In several instances, medications were not administered according to physician orders. For example, one resident received a lower dose of docusate sodium than prescribed, and another was nearly given expired medication, which was only prevented by surveyor intervention. Additionally, medications were administered outside the required time frames, with some residents receiving their scheduled morning medications significantly late, and without proper documentation or physician notification regarding the delay. The facility also failed to maintain proper medication disposal practices. The Discarded Medication Log was incomplete, lacking required dates, signatures, and witness documentation for numerous medications belonging to several residents. Unlabeled and expired medications, such as meropenem vials, were found stored in the medication cart after the prescribed course was completed, contrary to facility policy. These lapses were confirmed through interviews with nursing staff and the DON, who acknowledged that the required procedures for medication destruction and documentation were not followed. Furthermore, medication administration practices were not consistently supervised. In one case, a nurse left multiple medications at a resident's bedside for self-administration, despite the resident not being assessed or authorized for self-administration. The medications were taken late, outside the scheduled administration window, and without staff observation, which was contrary to both physician orders and facility policy. These deficiencies were identified through direct observation, record review, and staff interviews, all of which confirmed that established protocols for medication administration and documentation were not adhered to.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to ensure that insulin administration sites were rotated for two residents who were prescribed subcutaneous insulin, as required by physician orders, manufacturer guidelines, and professional standards. For one resident with a history of hemiplegia, diabetes mellitus, and gastrostomy status, records showed that insulin injections were repeatedly administered in the same abdominal quadrants over an extended period. Both the registered nurse and the Director of Nursing confirmed that the administration sites were not rotated as ordered, acknowledging that this practice did not comply with the physician's instructions, manufacturer recommendations, or facility policy. Another resident, diagnosed with type 2 diabetes mellitus and other conditions, also received insulin injections at non-rotated sites, primarily in the same abdominal quadrants. Medication administration records indicated multiple instances where the injection sites were not alternated. Interviews with nursing staff and the DON confirmed that the failure to rotate sites was a medication error, as it was not in accordance with the physician's order, manufacturer specifications, or accepted professional standards. Facility policies and procedures, as well as manufacturer guidelines for both types of insulin used, explicitly required rotation of injection sites to prevent adverse effects and ensure proper absorption. The facility's own definition of a medication error included failure to follow these requirements. The survey findings were based on direct record review, staff interviews, and policy examination, all of which demonstrated that the facility did not adhere to established protocols for insulin administration for the two residents reviewed.
Unlabeled and Expired Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors identified several deficiencies in the facility's management of medications and biologicals. In the medication room of Station A, two vials of meropenem, an intravenous antibiotic, were found unlabeled in the IV cart. The registered nurse confirmed that these vials should have been discarded after the prescribed course was completed, but they remained in the cart without proper labeling. Review of the resident's records indicated that the meropenem treatment had concluded, and the extra vials delivered by the pharmacy were not disposed of as required. In Station B, expired medications were found in the medication cart during inspection with the Infection Preventionist. Specifically, a container of psyllium and a bottle of docusate sodium, both used to treat constipation, were discovered with expiration dates that had already passed. The Infection Preventionist and Director of Staff Development both acknowledged that expired medications should be discarded, and that nurses are responsible for checking and removing such items from the cart. Further interviews with nursing staff confirmed that expired medications should not be present in medication carts and that staff are expected to check expiration dates before administration. The Director of Nursing reviewed facility policies, which require the disposal of expired and unlabeled medications and prohibit their storage or use. The presence of expired and unlabeled medications in both the medication room and carts was acknowledged as a failure to follow these established policies.
Pureed Food Consistency Not Maintained for Dysphagia Diets
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents on a dysphagia puree diet, as required by the International Dysphagia Diet Initiative (IDDSI) Level 4 standards. During observation of the trayline, pureed mixed vegetables were found to be too thick and did not pass the spoon tilt test, which is used to assess the appropriate consistency for safe swallowing. Staff responsible for preparing the puree did not perform the required spoon tilt test, instead relying solely on mixing and visual assessment. The Dietary Director confirmed that the puree mixed vegetables did not fall off the spoon as required and acknowledged that the consistency should have been adjusted by adding more liquid. Review of facility policies and recipes indicated that all IDDSI texture modifications must pass established testing methods at the start and every 15 minutes during service. The facility's diet manual and IDDSI guidelines specify that pureed foods must not be sticky, must fall off the spoon in a single spoonful, and must not have liquid separation. Despite these requirements, the puree mixed vegetables served did not meet the necessary consistency standards, potentially affecting all residents on a puree diet at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, labeling, and sanitation practices. During a kitchen tour, a dietary aide identified several food items, including tomato soup and stewed prunes, that were not disposed of by their expiration dates. Additionally, various produce items such as mixed grapes, oranges, apples, carrots, purple cabbage, and leafy lettuce were found without proper labeling of received or expiration dates. Other items, such as grated Parmesan cheese and sliced deli meat, were missing required opened and expired dates. A frozen pepperoni bag was also incorrectly labeled with an expiration date. Further observations revealed improper storage practices, such as sliced cheeses being mixed with avocados and grapes in a single bin, which the dietary aide acknowledged should not occur due to contamination risks. A bin of thickener powder was found in the dry storage room without a product name, opened date, or expiration date, and was not stored in its original packaging as required. One of three plate warmer machines was found to have dried food debris, indicating it had not been cleaned as per facility policy. Interviews with the dietary director confirmed that staff are expected to inspect, label, and date all food items upon receipt and opening, and to store produce separately to prevent cross-contamination. The director also stated that opened food items should be discarded after three days and that equipment should be kept clean and in optimal working condition. Facility policies reviewed by surveyors supported these expectations, indicating that the observed practices were not in compliance with established procedures.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for multiple residents, as evidenced by surveyor observations, interviews, and record reviews. For one resident with a history of vancomycin-resistant enterococcus (VRE), staff did not implement Enhanced Barrier Precautions (EBP) as ordered, including the absence of required signage and personal protective equipment (PPE) at the room entrance. Staff members entered the resident's room and provided care, such as medication administration and linen changes, without wearing gowns, contrary to facility policy and physician orders. The Infection Preventionist and Director of Nursing confirmed that EBP should have been implemented for this resident due to their history of multidrug-resistant organisms (MDROs), but it was not done. In another instance, a Restorative Nursing Aide used a cloth gait belt with a resident on EBP and failed to properly disinfect it between uses. The aide stated she used bleach wipes on the cloth gait belt and then used it with another resident. The Infection Preventionist clarified that cloth gait belts are porous and cannot be properly disinfected with wipes, and that only vinyl gait belts should be used. The Director of Nursing confirmed that improper disinfection of shared equipment could lead to the spread of infection. Additionally, multiple medication carts were found with Prostat supplement bottles that were sticky and had visible drippings, indicating they were not cleaned before and after use as required by facility policy. Further deficiencies included staff not wearing gowns during high-contact care activities for residents on EBP, such as providing bed baths, and not securing gowns properly during medication administration. Linen carts were observed with loosely woven mesh covers that did not fully protect linens from dust. In the respiratory care area, a BiPAP mask was not stored in a manner free from contamination, and the nebulizer was not labeled with the resident's name or date last changed. Documentation and cleaning of the BiPAP equipment were inconsistent and not in accordance with physician orders or manufacturer instructions. These practices were confirmed by staff interviews and policy reviews, demonstrating a failure to follow established infection control protocols.
Cluttered Therapy Gym Limits Resident Access to Rehabilitative Services
Penalty
Summary
Facility staff failed to provide sufficient space and appropriate storage for equipment in the Physical Therapy (PT) gym, resulting in the therapy mat and surrounding area being used to store various items, including therapy balls, broken equipment, assistive devices, and items meant for disposal. Observations revealed that these items were stacked on and around the therapy mat, rendering the area unusable for resident therapy sessions. The Director of Rehabilitation confirmed that the therapy mat and its surrounding area could not be used for therapy due to the clutter and that items stored there were awaiting disposal. Interviews with facility leadership, including the Director of Nursing, emphasized the importance of maintaining a tidy, homelike, and hazard-free therapy environment, and acknowledged that the current use of the therapy area for storage was inappropriate. A review of facility policy indicated an expectation for cleanliness and order to promote a homelike environment, but there was no specific policy addressing the maintenance of uncluttered therapy areas or prohibiting the use of therapy spaces for storage.
Failure to Maintain Safe Equipment and Environment for Residents
Penalty
Summary
The facility failed to maintain essential equipment in safe working condition in several areas, as observed during surveyor inspections. In the kitchen, the light bulb inside the freezer used to store milk was found to be non-functional. Staff members, including the Dietary Aide and Dietary Director, were unaware of the issue, and the broken bulb had not been reported or addressed. Facility policy required that equipment be kept in optimal working condition and that staff notify supervisors and maintenance when repairs are needed, but this process was not followed. In the resident care areas, two residents were affected by unsafe equipment conditions. One resident, with a history of dementia, cerebral palsy, and high fall risk, was found with a bed controller that had exposed wires at its base. Multiple staff, including a CNA, Maintenance Supervisor, and DON, confirmed the presence of exposed wires and acknowledged that maintenance should have been notified immediately. The facility's policies emphasized the importance of maintaining equipment in good repair and ensuring a safe environment, but the required notifications and repairs were not made in a timely manner. Another resident, who had hemiplegia, aphasia, and was also at high risk for falls, was found to have wall sockets at the head of the bed that were cracked and missing covers. Staff interviews confirmed that these hazards had not been reported to maintenance as required. Facility policies outlined the responsibility of staff to identify and report hazards and for maintenance to keep the environment safe and homelike, but these procedures were not followed, resulting in unsafe conditions for the residents.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) assisted a resident with breakfast while standing over the resident, rather than sitting at eye level as required by facility policy. The resident involved had a history of pneumonia, dementia, and major depressive disorder, and was assessed as having severely impaired cognition and requiring total assistance with all activities of daily living. During the observation, the resident was in bed with the head elevated, and the CNA admitted to forgetting to get a chair, acknowledging that staff should be at eye level to respect the resident's dignity during mealtime assistance. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) confirmed that staff are expected to sit at eye level when assisting residents with eating, both for dignity and safety reasons. Facility policies reviewed also specified that residents should be assisted with meals in a manner that maintains their dignity, explicitly stating that staff should not stand over residents while feeding them. The failure to follow these procedures resulted in care that did not maintain the resident's dignity.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed in advance about the risks and benefits of a psychoactive medication, specifically Remeron (mirtazapine), which was prescribed for depression manifested by poor appetite. The resident had a history of chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder, and was assessed as being able to make needs known but unable to make medical decisions. Despite this, there was no documented informed consent for the use of Remeron, as confirmed during interviews and record reviews with facility staff. The MDS Nurse and a Registered Nurse both acknowledged that the informed consent process was missed, with the RN stating she failed to complete the consent when the medication order was received. The Director of Nursing confirmed that it is the responsibility of licensed nurses to obtain informed consent prior to administering such medications, in accordance with facility policy. The facility's policy requires verification of informed consent with each order, but this was not followed in this instance.
Failure to Assess and Authorize Medication Self-Administration
Penalty
Summary
The facility failed to ensure that medication self-administration was clinically appropriate and did not honor a resident's right to self-administer medications. A resident with multiple diagnoses, including polyneuropathy, hypertension, major depressive disorder, anxiety disorder, binge eating disorder, and intellectual disabilities, was observed with medications left at the bedside for self-administration. The resident had previously been assessed as not wanting to self-administer medications and not being a candidate for safe self-administration. Despite this, a nurse left several medications at the bedside at the resident's request, without conducting a new assessment or obtaining a physician's order for self-administration. The resident was able to communicate effectively and had the capacity to make decisions, as documented in the medical record. During an interview, the resident confirmed that the medications belonged to them and that the nurse left them at the bedside because the resident preferred to take them one at a time. The nurse confirmed leaving the medications for the resident to self-administer, stating that the resident was alert and often requested this arrangement. However, the nurse acknowledged that the facility's process required an assessment and a physician's order before allowing self-administration, neither of which were completed in this case. Further review and interviews with facility staff, including the RN and DON, confirmed that the facility's policy required an interdisciplinary assessment and physician's order before permitting self-administration of medications. The staff recognized that the process was not followed when the nurse left medications at the bedside without proper assessment or documentation. Facility policies also specified that medications should not be left unattended at the bedside unless authorized, and that residents' rights to self-administer medications must be supported by a clinical determination of safety and appropriateness.
Call Light Not Connected for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, hemiplegia following a stroke, aphasia, and major depressive disorder was found in bed with their call light clipped to the sheet but disconnected from the wall. The resident required substantial to total assistance with all activities of daily living and was assessed as a fall risk. The care plan for this resident included an intervention to keep the call light and frequently used items within reach to minimize the risk of falls or injury. During an observation, a CNA confirmed that the call light was not plugged in and stated that all residents' call lights should be connected to the wall at all times to ensure proper functioning. The CNA acknowledged that staff are responsible for ensuring call lights are plugged in and operational before leaving residents' rooms. The DON also confirmed that staff should ensure call lights are connected and functioning to allow residents to call for assistance. Review of facility policy indicated that call lights should be plugged in at all times and answered promptly.
Failure to Develop Baseline Care Plans for Residents with Oxygen Therapy and Anticoagulant Orders
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with significant medical needs. For one resident admitted with diagnoses including pneumonia, chronic respiratory failure, and COPD, there was a physician order for oxygen therapy at 2 liters per minute via nasal cannula three times a day. Despite these orders and the resident's intact cognitive status, no baseline care plan addressing oxygen therapy was created or implemented. Both the registered nurse and the director of nursing confirmed that a baseline care plan should have been in place to address the resident's primary respiratory issues and to serve as a communication tool for coordinated care. For another resident admitted with chronic embolism, thrombosis, atrial fibrillation, and atherosclerosis of the aorta, there was a physician order for the anticoagulant Pradaxa to be administered twice daily. This resident had severe cognitive impairment and was identified as being on a high-risk drug class. Despite the order for anticoagulant therapy, no baseline care plan was developed to address the use of Pradaxa, including monitoring for adverse effects and identifying interventions to manage potential complications. The registered nurse acknowledged that a baseline care plan should have been initiated upon admission to ensure proper monitoring and care. The facility's policy and procedure on baseline care plans, last reviewed in January 2025, requires that a baseline plan of care be developed within 48 hours of admission to meet each resident's immediate health and safety needs. This plan must include initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The failure to develop and implement these baseline care plans for the two residents resulted in a deficiency related to the timely provision of essential healthcare services.
Failure to Schedule Orthopedic Appointment Following Physician Orders
Penalty
Summary
The facility failed to follow up and schedule an orthopedic appointment for a resident who was admitted with diagnoses including a disorder of bone, primary osteoarthritis of the right knee, and generalized muscle weakness. The resident's history and physical indicated possible lytic erosive bone changes in the femur, with a recommendation for an orthopedic referral. Physician orders were documented on two occasions to arrange for an orthopedic appointment, specifically for a lytic lesion in the left femur. Despite these orders, there was no evidence that the appointment was scheduled or that appropriate follow-up occurred. Interviews with nursing staff and the Director of Nursing revealed that the responsibility for scheduling the appointment and documenting follow-up was not fulfilled. The facility's policy required coordination between social services and nursing for such referrals, but this process was not completed as expected. The lack of action resulted in a delay of care and treatment for the resident, as the necessary orthopedic evaluation was not arranged in a timely manner.
Failure to Set Low Air Loss Mattress According to Resident Weight for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that two residents at high risk for pressure ulcers received care consistent with professional standards, specifically regarding the use of low air loss mattresses (LALM) set according to each resident's weight. For one resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, adult failure to thrive, and on palliative care, the LALM was observed set at 130 lbs, while the resident's actual weight was 158 lbs and the manufacturer's instructions indicated the setting should be between 150-180 lbs. Both a CNA and an LVN confirmed the setting was incorrect and acknowledged the importance of matching the mattress setting to the resident's weight to prevent pressure injuries. The DON also confirmed that the LALM should be set according to the resident's weight and that staff are responsible for ensuring this is done. For a second resident with diagnoses including abnormalities of gait, muscle weakness, and chronic embolism and thrombosis, the LALM was observed set at 270 lbs, while the resident's weight was 152 lbs and the manufacturer's instructions indicated the setting should be between 120-150 lbs. An LVN confirmed the setting was incorrect and stated that improper settings could cause pressure injuries. The DON reiterated that the LALM should be set according to the resident's weight and that staff are responsible for monitoring and reporting any discrepancies. In both cases, the facility's policy and procedure, as well as the manufacturer's specifications, required the LALM to be set based on the resident's weight. The failure to follow these guidelines resulted in the residents not receiving care consistent with professional standards for the prevention of pressure ulcers, as confirmed by staff interviews and documentation review.
Failure to Provide Ordered Range of Motion Exercises to Both Upper Extremities
Penalty
Summary
A deficiency occurred when a resident with osteoarthritis and chronic obstructive pulmonary disease, who had moderate cognitive impairment and decreased range of motion (ROM) in both upper extremities, did not receive the ordered active assisted range of motion (AAROM) exercises to the left upper extremity during a restorative nursing aide (RNA) session. The resident's care plan and physician orders specified that AAROM exercises were to be performed on both upper extremities daily to maintain or improve ROM and prevent further decline. However, during observation, the RNA only performed exercises on the right upper extremity and applied a splint, omitting the left side entirely. The RNA later acknowledged that the omission was due to the belief that the resident could move the left upper extremity independently, despite the care plan and orders requiring assistance for both sides. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed the importance of following RNA orders to prevent decline in mobility and function. Facility policy also required that restorative nursing care be provided as needed to promote optimal safety and independence, which was not followed in this instance.
Failure to Follow Enteral Feeding Protocols and Labeling Requirements
Penalty
Summary
Staff failed to follow facility protocols for the care and administration of enteral nutrition for two residents with gastrostomy tubes. For one resident with severe cognitive impairment and a history of dysphagia and malnutrition, observations revealed that the feeding formula and water flush bag were not labeled with the time they were hung or the rate of infusion, as required by physician orders and facility policy. Additionally, a specialized valve used with the feeding tube was disconnected and left uncapped, hanging from the feeding pump pole, contrary to infection control protocols. Interviews with nursing staff and the Director of Nursing confirmed that these labeling and handling procedures were not followed, which are necessary to ensure accurate administration and prevent contamination. For another resident with hemiplegia, aphasia, and severe cognitive impairment, the water flush bag was observed without the required label indicating the administration rate and frequency. Nursing staff acknowledged that the label should have included this information to ensure the resident received the correct amount of water flushes as ordered by the physician. The Director of Nursing confirmed that the omission of this information on the label did not comply with facility policy and could result in the resident not receiving the prescribed hydration. Record reviews for both residents showed clear physician orders for the administration of enteral nutrition and water flushes, specifying rates, frequencies, and labeling requirements. Facility policy and procedures also outlined the need for accurate labeling and safe handling of enteral feeding equipment to prevent errors and contamination. Despite these protocols, staff did not consistently implement them, as evidenced by direct observations and staff interviews.
Annual Staff Competency Evaluation Not Performed as Required
Penalty
Summary
The facility failed to ensure that staff competency evaluations were performed annually for one of six sampled staff members, specifically a Certified Nursing Assistant (CNA). Review of the CNA's employee file showed that the last skills competency evaluation was completed in January 2024, despite the CNA being employed since November 2022. The Director of Staff Development (DSD) indicated that the next competency evaluation was scheduled for November 2025, aligning with the month of hire rather than the annual requirement. The Director of Nursing (DON) confirmed that skills competency evaluations are supposed to be conducted annually and acknowledged that the evaluation for this CNA was overdue as of January 2025. Facility policy on performance evaluations requires that each employee's job performance be reviewed and evaluated at least annually, with skills competency being a component of this process. The DON stated that the DSD was responsible for conducting these evaluations and that the failure to perform the annual skills competency check was an oversight. The facility's policy on staffing also emphasizes the need for sufficient and competent nursing staff to provide care in accordance with resident care plans and facility assessments.
Medication Error Rate Exceeds Acceptable Threshold Due to Dosage and Expiration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a nurse administered an incorrect dosage of docusate sodium to a resident with chronic obstructive pulmonary disease, a history of falls, and fibromyalgia. The physician's order specified 250 mg of docusate sodium twice daily, but the nurse administered only 100 mg. This discrepancy was confirmed through record review and interviews with nursing staff and the Director of Nursing, who acknowledged that the medication was not given as ordered and that the lower dose would not be as effective in treating the resident's constipation. In the second instance, another nurse failed to check the expiration date before preparing docusate sodium for a resident diagnosed with dementia, constipation, and hypertension. The medication bottle had expired, but the nurse did not notice this until it was pointed out by the surveyor during the medication pass. The nurse admitted to not reading the expiration date, and facility staff confirmed that expired medications should not be administered due to safety concerns and potential ineffectiveness. Both incidents were observed during medication administration and were corroborated by interviews with nursing staff, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing. Facility policy required medications to be administered according to prescriber orders and for expiration dates to be checked prior to administration, but these procedures were not followed in either case.
Delayed CT Scan Resulted in Missed Timely Orthopedic Follow-Up
Penalty
Summary
The facility failed to provide a timely computed tomography (CT) scan for one resident who had a right humeral neck fracture and muscle wasting. The CT scan was ordered by the orthopedic physician on 9/9/2024, with instructions for the resident to return to the orthopedic physician in one week with the scan results. However, the facility delayed requesting authorization for the CT scan until 10/9/2024, despite the order being received a month earlier. The business office was responsible for submitting authorizations for radiology services, but could not provide a reason for the delay in requesting authorization. Nursing notes indicated that the orthopedic follow-up appointment was cancelled due to the lack of a completed CT scan, and the resident was only able to attend the CT scan appointment on 10/21/2024, more than a month after the initial order. Interviews with facility staff, including the LVN, Business Office Manager, and DON, confirmed that the delay in obtaining the CT scan was due to the late submission of the authorization request. The DON acknowledged that radiology orders should be processed the same day they are received and that the delay in obtaining the CT scan was not appropriate. Facility policy required staff to process test requisitions and arrange for tests based on physician orders, but this was not followed in this case, resulting in a significant delay in diagnostic imaging and follow-up orthopedic care for the resident.
Failure to Ensure Proper Training and Competency in Puree Food Preparation for Dysphagia Diets
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in preparing pureed foods for residents on a dysphagia puree diet, as required by the International Dysphagia Diet Initiative (IDDSI) guidelines. During observation of the trayline, a cook was unable to verbalize or demonstrate the correct preparation of pureed mixed vegetables to achieve the required consistency. The pureed mixed vegetables were observed to be too thick and did not pass the spoon-tilt test, a standard method for assessing appropriate texture for safe swallowing. The cook stated that her method for checking consistency was limited to mixing the puree and adjusting with liquid or thickener based on feel, without performing the required spoon-tilt test. The Dietary Director confirmed that oversight was provided through spot checks and taste testing, but acknowledged that the puree mixed vegetables did not pass the spoon-tilt test during the trayline and should have been adjusted before service. The facility's recipe and policy documents specified that all IDDSI texture modifications must pass established testing methods at the start and every 15 minutes during service, but this protocol was not followed. Review of the competency checklist for the cook revealed that it did not include topics related to IDDSI Level 4 testing, such as the spoon-tilt or fork-drip tests. The facility's diet manual and IDDSI guidelines require that pureed foods for residents with dysphagia be lump-free, not sticky, and able to fall off a spoon in a single spoonful, with no separation of liquid and solid. The failure to properly prepare and test the puree consistency as outlined in facility policy and IDDSI standards resulted in the serving of food that did not meet safety requirements for residents on a dysphagia puree diet.
Failure to Provide Occupational Therapy as Ordered
Penalty
Summary
The facility failed to provide occupational therapy (OT) treatments five times a week as required by the OT plan of treatment and care plan for one resident. The resident, who was admitted with muscle wasting, atrophy, and a right humeral neck fracture, had moderate cognitive impairments and significant functional limitations, including dependence for dressing, bathing, and transfers. The care plan and OT evaluation both specified daily OT sessions five times a week for four weeks. However, OT treatment encounter notes showed that while the prescribed frequency was met during the first three weeks, the resident only received four sessions in the fourth week, and just one session per week in the subsequent two weeks. The Director of Rehabilitation confirmed during interview and record review that the resident did not receive OT treatment at the frequency specified in the plan of care, and there was no documentation explaining the missed sessions. The facility's policy required staff occupational therapists to follow relevant physician orders and implement treatment plans in consultation with the resident's physician, but this was not adhered to in this case.
Failure to Maintain Accurate and Timely Clinical Documentation
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for two residents, resulting in deficiencies related to documentation standards. For one resident, the Occupational Therapy (OT) Progress Notes and Discharge Summary were not completed within the required timeframe. The OT Progress Report dated 2/24/2025 was signed and completed on 3/4/2025, and the OT Progress Report dated 3/3/2025, as well as the OT Discharge Summary dated 3/4/2025, were both signed and completed on 3/17/2025. The Director of Rehabilitation confirmed that these documents were completed very late and emphasized the importance of timely documentation for continuity of care and accurate communication among healthcare providers. The facility's policy required progress reports and discharge summaries to be completed within seven days, which was not followed in these instances. Another deficiency was identified in the medication administration documentation for a different resident. The Licensed Vocational Nurse (LVN) left medications at the resident's bedside for self-administration, and the resident did not take them at the scheduled time. The LVN later documented in the Medication Administration Record (MAR) that the medications were administered during the scheduled morning pass, even though the resident actually took them later. The LVN admitted to documenting the administration before the resident took the medications and acknowledged that the MAR did not accurately reflect the actual time of administration. The Director of Nursing confirmed that the MAR should accurately document the time medications are given, as it is used by staff and physicians to track medication administration. Both deficiencies were confirmed through interviews, record reviews, and observations. The facility's policies and procedures for clinical documentation and medication administration were not followed, resulting in inaccurate and untimely records. These lapses in documentation could lead to miscommunication among staff and incomplete information regarding the care and services provided to residents.
Failure to Accurately Document Antibiotic Use in Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for one resident by not accurately documenting antibiotic use in the Antibiotic Log. A resident was admitted with multiple diagnoses, including low back pain, history of falling, and hypertension. The resident was diagnosed with a urinary tract infection (UTI) and initially prescribed ciprofloxacin. The order for ciprofloxacin was discontinued the next day after urine culture and sensitivity results indicated resistance, and the antibiotic was changed to Keflex. However, the Antibiotic Log incorrectly showed ciprofloxacin as being administered for a full course and did not include any documentation of the Keflex prescription, including its start and completion dates. Interviews with facility staff, including the RN, Infection Preventionist (IP), and Director of Nursing (DON), confirmed that the Antibiotic Log was incomplete and not updated according to facility policy. The DON and IP acknowledged that the log should have reflected the change in antibiotics and that it is facility policy to monitor and document all antibiotic use. Review of the facility's policies further confirmed the requirement for accurate documentation and monitoring of antibiotic administration by the IP nurse.
Failure to Implement Bed Alarm as Care Planned for Fall Prevention
Penalty
Summary
The facility failed to implement a person-centered care plan for one resident by not ensuring that the resident's bed alarm was functioning as indicated in the care plan for fall prevention. The resident, who had a history of falls, unspecified dementia, and a recent fracture of the thoracic vertebrae, was admitted with a care plan intervention requiring a bed alarm while in bed. The care plan was reviewed and agreed upon by the resident's family member and the interdisciplinary team. However, during observation, the resident was able to move in bed without the bed alarm sounding, and both the resident and staff confirmed that the bed alarm was not in use or functioning at that time. Further investigation revealed that the bed alarm device was present but not turned on, and the sensor pad was not connected to the alarm machine. Staff interviews confirmed that the bed alarm should have been checked and ensured to be operational as part of the resident's care plan. The facility's policy emphasized the importance of individualized care plans and the responsibility of staff to implement interventions as designed. The failure to follow the care plan placed the resident at risk for falls and injury.
Failure to Ensure Bed Alarm Function and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to follow its fall prevention policy for a resident with a history of falls and multiple risk factors. The resident, who had diagnoses including unspecified thoracic vertebrae fractures, dementia, hypertension, osteoporosis, and a recent fall, experienced another fall resulting in a displaced proximal humerus fracture. Despite the care plan indicating the use of a bed alarm as an intervention, observations revealed that the bed alarm was not turned on or functioning. Staff interviews confirmed that the bed alarm was either not present or not operational, and the device was found disconnected from its sensor pad during inspection. Additionally, the facility did not accurately assess the resident's fall risk following the incident. The Fall Risk Assessment assigned a low-risk score, despite the resident's multiple predisposing conditions such as hypertension, osteoporosis, fractures, and a history of falls. Both the Director of Staff Development and the Director of Nursing acknowledged that the assessment was incorrect and that the resident should have been classified as high risk for falls based on her medical history and recent events. The facility's policies required staff to use devices like bed alarms as nursing interventions to prevent injury and to conduct thorough fall risk assessments considering all relevant diagnoses and recent incidents. However, the failure to ensure the bed alarm was functioning and the inaccurate fall risk assessment led to inadequate supervision and interventions for the resident, contrary to facility policy and procedure.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within 24 hours to the State Survey Agency (SSA) and the Ombudsman, as required by its policies and procedures on abuse. This deficiency involved a resident who was admitted with diagnoses including inflammatory polyarthropathy, low back pain, and dementia, which severely impaired their cognitive skills for daily decisions. On the morning of March 5, 2025, the resident was found with a swollen, red, and painful right hand, which was later diagnosed as an acute fracture of the fifth metacarpal. The incident was initially observed by a Certified Nursing Assistant (CNA) who reported it to a Registered Nurse (RN). The RN then informed the Director of Nursing (DON) about the resident's condition. Despite the immediate recognition of the injury, the facility delayed reporting the incident to the SSA and Ombudsman until the following day, after confirming the fracture through an X-ray. The facility's policy required reporting within 24 hours of any injury of unknown origin, regardless of the confirmation of a fracture. Interviews with facility staff, including the Licensed Vocational Nurse (LVN), CNA, RN, DON, and Administrator, revealed a misunderstanding of the reporting timeline. The DON and Administrator acknowledged that the report should have been made within 24 hours of the initial observation of the swelling, not after the X-ray confirmation. This delay in reporting potentially placed the resident at risk for unidentified abuse while under the facility's care.
Inaccurate Medication Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, which had the potential to cause confusion in care. The resident, who was admitted with diagnoses including inflammatory polyarthropathy, low back pain, and dementia, was noted to have severely impaired cognitive skills and required maximum assistance for daily activities. On a specific date, a Certified Nursing Assistant reported to a Registered Nurse that the resident's right hand was swollen and painful. The physician was notified, and an order for an X-ray and acetaminophen was given. However, the Medication Administration Record indicated that acetaminophen was administered before the physician's order was documented, leading to inaccurate documentation of the medication administration time. During interviews and record reviews, it was confirmed that the Registered Nurse documented an incorrect time for the administration of acetaminophen, which was given before the physician's order was officially recorded. The Director of Nursing acknowledged the discrepancy and stated that the nurse should have documented the exact time the medication was administered after the physician's order. The facility's policy on charting and documentation emphasized the need for complete and accurate records, which was not adhered to in this instance.
Breach of Resident's Medical Record Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN) left an electronic health record (EHR) open, unattended, and out of view. This incident involved a resident who had been admitted to the facility with diagnoses including liver cell carcinoma, type 2 diabetes mellitus, and peripheral angiopathy. The resident was dependent on assistance for various daily activities, as indicated in their Minimum Data Set (MDS). During an observation and interview, it was noted that the LVN left the EHR open to the resident's chart while administering medications in the resident's room, with the computer out of sight. The LVN acknowledged that leaving the computer unattended posed a risk of unauthorized access to the resident's records, which is a violation of the Health Insurance Portability and Accountability Act (HIPAA) standards. The Assistant Director of Nursing (ADON) confirmed that the LVN should have ensured the computer was turned off or secured if left unattended. The facility's policy and procedures on HIPAA training emphasize the importance of maintaining the confidentiality of residents' protected health information. This incident highlights a failure to adhere to these policies, resulting in a breach of the resident's right to privacy and confidentiality.
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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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