Avondale Villa Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Livermore, California.
- Location
- 788 Holmes Street, Livermore, California 94550
- CMS Provider Number
- 555399
- Inspections on file
- 18
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avondale Villa Post-acute during CMS and state inspections, most recent first.
A severely cognitively impaired, highly dependent resident was found by CNAs and LVNs to have a new purplish bruise on the lower chin/near the lip, with staff consistently unable to identify a cause. The bruise was documented in clinical notes as a new skin discoloration, and internal notifications were made, but the administrator confirmed that the incident was not reported to CDPH, law enforcement, or the Ombudsman, despite facility policy requiring immediate external reporting of suspected injuries of unknown origin.
Surveyors found that the facility did not maintain proper infection control practices, including unclear cleaning status and improper storage of a shared Hoyer lift, failure to follow Enhanced Barrier Precautions for a resident with a stage 4 pressure ulcer and wound vac, and improper cleaning and disinfection of a shared glucometer between resident uses. Staff did not consistently follow manufacturer instructions or facility policy for cleaning and disinfection, and required personal protective equipment was not always used during high-contact care.
An LVN administered a hazardous drug, finasteride, to a resident without wearing gloves, despite the medication being labeled as hazardous and facility policy requiring PPE. The resident’s MAR did not indicate the need for precautions, and the DON confirmed that gloves should be used when handling such medications.
The facility did not maintain documentation or a witnessed process for the destruction of discontinued non-narcotic prescription medications. Nurses were allowed to destroy these medications without records, and there was no designated storage area for discontinued drugs. The policy did not address documentation requirements for non-narcotic medication destruction, and the consultant pharmacist was not involved in this process.
A resident with GERD, diabetes, kidney disease, and heart issues was given both pantoprazole and omeprazole, two PPIs, at the same time after a hospitalization. Nursing staff did not identify or address the duplicate therapy, and the facility's consultant pharmacist confirmed there was no benefit to this practice. Facility policies requiring medication review were not followed.
Three medication administration errors were observed, resulting in a facility-wide medication error rate of 9.52%. Errors included a nurse giving a resident Robitussin DM instead of plain Robitussin, another nurse administering Senna instead of the prescribed Senna-Docusate combination to a resident, and a nurse applying a 4% lidocaine patch instead of the ordered 5% strength to another resident. These errors occurred due to failure to follow prescriber orders and verify medication details as required by facility policy.
Surveyors found expired Covid-19 testing products, vaccines with unclear expiration dates, and co-mingled supplies for IV use and foley catheters in the medication room, along with expired swabs for throat infection. The treatment cart contained opened, single-use sterile wound care products and additional expired swabs. Facility staff acknowledged the findings, and interviews revealed that monthly checks were not detailed enough to prevent these deficiencies.
A resident's two bottles of apple juice, one expired and one undated, were found stored in the staff refrigerator instead of the designated resident food refrigerator, in violation of facility policy. The expired juice was not discarded as required, and the improper storage was confirmed by both the DSD and DON during interviews.
Two rooms were found to provide less than the required 80 square feet per resident, with each room housing four residents in spaces measuring 77.24 and 72.1 square feet per person. Despite residents and staff reporting no issues with space, privacy, or care delivery, the rooms did not meet regulatory size standards.
The facility failed to employ a qualified nutrition professional to manage food and nutrition services, leading to multiple issues such as improper food handling, serving cold and unpalatable food, not fortifying diets for residents who needed it, and not maintaining accurate resident food preferences. The DSS was not present full-time, and the RD worked part-time, contributing to these deficiencies.
The facility failed to ensure food and nutrition staff had the appropriate competencies and skills set, leading to improper thawing of frozen food, incorrect sanitizer strength checks, and inaccurate dish wash machine temperature recordings. Staff admitted to not monitoring time or temperature during thawing, and logs showed repeated temperatures for multiple cycles.
The facility failed to provide food items according to the menu when nine residents on a regular diet were not served with one teaspoon of margarine at lunch. This was observed during a lunch tray line observation, where no margarine was served on any resident lunch tray. The facility's Winter Menus indicated that one teaspoon of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. This failure had the potential for residents to receive inadequate caloric intake.
The facility failed to serve palatable food at the appropriate temperature. Residents reported receiving cold, bland, and poorly textured meals. Observations confirmed that food temperatures were below the required standards, and the kitchen lacked proper equipment to maintain hot food during service.
The facility failed to store, prepare, distribute, and serve foods in a sanitary manner, leading to potential foodborne illness risks. Issues included improper cool down methods, incorrect thawing and refreezing of food, spoiled cherry tomatoes, improper storage of cooked and raw meats, unlabeled and undated food items, improper handling of drinkware, and inadequate cleaning of the ice machine.
A resident with a history of stroke and dementia experienced repeated unwitnessed falls due to inadequate supervision and lack of necessary safety equipment. Despite being identified as high risk for falls, the facility did not consistently implement the required stand-by assistance during transfers, leading to multiple incidents where the resident was found on the floor after attempting to transfer without help.
The facility failed to ensure that pureed food was prepared to the appropriate consistency for six residents. Observations revealed that pureed chili, cornbread, beef roast, and zesty spinach were too thin and runny, not adhering to the Registered Dietician's guidelines for pureed food to be smooth, moist, and able to hold its shape.
The facility failed to offer a substitute when milk was not provided as per the planned menu and did not maintain an accurate system for recording residents' food preferences. One resident reported receiving cold food and having lactose intolerance, but her preferences were not accurately reflected. The facility's administrative documents were outdated and not maintained within the licensed building.
The facility failed to provide physician-prescribed therapeutic diets to residents, as observed during multiple lunch tray line observations. Six residents on a Fortified diet did not receive supplemental food items, three residents on a Consistent Carbohydrate diet received regular diet items, and one resident with a diet order for extra protein did not receive additional meat as prescribed.
The facility failed to document medication administration for three residents on multiple occasions in February 2024. Both the DON and an LVN admitted to administering the medications but did not document them due to being too busy and, in one case, falling ill and forgetting to document upon return to work.
The facility failed to maintain the dishwashing machine's water temperature within the manufacturer's recommended range, risking insufficient sanitization of dishware. Observations and records showed discrepancies in recorded and actual temperatures, indicating non-compliance with sanitation standards.
The facility failed to complete baseline care plans within 48 hours of admission for three residents and did not provide them or their representatives with a summary of the baseline care plan. The DON confirmed that the baseline care plans were not developed within the required timeframe and that summaries were not provided.
The facility failed to implement a care plan for a resident at risk of aspiration due to dysphagia. Despite a physician's order for a provale cup, staff used a regular plastic cup, leading to frequent coughing. The change was not communicated to the speech therapist, and no care plan addressed the resident's risk.
The facility failed to assess a resident who experienced severe weight loss, despite the resident's multiple diagnoses and significant weight changes. The last nutrition-related documentation by an RD was several months old, and the care plan was not updated in a timely manner. Interviews with staff revealed that the required assessment and intervention process was not followed.
The facility failed to ensure that two residents were free from unnecessary drugs when psychotropic medications were administered without adequate clinical indication and monitoring. One resident received Ziprasidone without documented behavioral symptoms or side effect monitoring, while another received Zyprexa and Trazodone without adequate monitoring and PRN Lorazepam without non-pharmacological interventions first. The facility did not follow its policy on psychotropic medication use and PRN orders.
The facility failed to use a prescribed provale cup for a resident at risk for aspiration and did not consult the Speech Therapist for alternative recommendations when the resident refused the cup. This led to the resident being given water from a plain plastic cup, resulting in frequent coughing during meals.
The facility had two resident rooms with multiple beds that did not meet the required 80 square feet per resident. Staff and residents reported no issues with space for care or belongings, but the rooms did not comply with regulatory space requirements. No negative consequences were observed, and a room size waiver was recommended.
Failure to Report Injury of Unknown Origin to Required External Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin for a severely cognitively impaired resident as required by law and by the facility’s own abuse reporting policy. The resident’s MDS indicated severe cognitive impairment and dependence on staff for most ADLs, including toileting, showering, transferring, and substantial assistance with eating, oral hygiene, and bed mobility. Multiple CNAs and LVNs observed a new bruise on the resident’s lower left chin/near the lip on or around 2/4/26, described as purple or purplish-blue, small, round or irregular, and approximately 1/4 to 1/2 inch in size. CNAs reported the bruise to charge nurses/LVNs, and documentation in the SBAR and skin assessment on 2/4/26 noted a new skin discoloration on the left chin area, with no complaints of pain or distress and the resident sleeping during the shift. Staff consistently stated they did not know what caused the bruise, and one CNA believed no one knew how it happened. Despite the unknown cause of the facial bruise and the resident’s severe cognitive impairment and dependence on staff, the administrator acknowledged that the bruise was not reported to CDPH, local law enforcement, or the Ombudsman. The facility’s written policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022, states that all reports of resident abuse, including injuries of unknown origin, must be reported to local, state, and federal agencies as required by regulations, and that suspected injuries of unknown source must be reported immediately to the administrator and appropriate external agencies, including the state licensing/certification agency, the ombudsman, and law enforcement. Although the physician and resident representative were notified, the required external reporting to regulatory and protective agencies did not occur, resulting in the failure to ensure the injury of unknown origin was reported as required by law.
Infection Control Failures in Equipment Cleaning, Enhanced Barrier Precautions, and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several key areas. During an observation in the utility room, two Hoyer lifts were found, with one positioned in a red-taped area labeled as 'DIRTY AREA' and a nearby cabinet labeled 'CLEAN AREA' containing unopened medical supplies. The Infection Preventionist (IP) stated uncertainty about whether the Hoyer lift was clean or dirty and acknowledged that the lift did not fit in the designated dirty area, raising concerns about potential cross-contamination. Review of records showed that seven residents used the Hoyer lift, and facility policy required cleaning and disinfecting reusable equipment between residents, in accordance with CDC guidelines. In another instance, the facility did not follow Enhanced Barrier Precautions (EBP) protocol for a resident with a stage 4 sacral pressure ulcer and a wound vac. The resident's care plan and physician order required staff to use gowns and gloves during high-contact care activities. However, a Certified Nursing Assistant (CNA) was observed providing direct care to the resident without wearing a gown, despite signage indicating the need for EBP. The CNA later confirmed awareness of the precautions but admitted to not following them during care, and the Director of Nursing (DON) confirmed that the required precautions were not followed during the incident. Additionally, the facility failed to properly clean and disinfect a shared glucometer between resident uses. During a medication pass, a Registered Nurse (RN) was observed wiping the glucometer with a single disinfecting wipe for less than ten seconds before returning it to the medication cart. Manufacturer instructions and facility policy required a two-step process using two wipes, with the device remaining wet for a specified contact time. The RN acknowledged not following the correct procedure, and both the DON and IP confirmed the expectation for staff to adhere to the two-step cleaning and disinfection process.
Failure to Use PPE During Hazardous Drug Administration
Penalty
Summary
Nursing staff failed to follow professional standards and facility policy for the safe handling of hazardous drugs during medication administration. During a medication pass observation, an LVN administered a tablet of finasteride, which was clearly labeled as a hazardous drug, to a resident without wearing gloves. The LVN removed the tablet from the bubble pack with bare hands and placed it into a medication cup before giving it to the resident. The resident’s Medication Administration Record did not indicate the need for gloves or other precautions when administering the drug. The facility’s policy required the use of appropriate personal protective equipment, including gloves, when handling hazardous drugs. Additionally, CDC and NIOSH guidelines specify that gloves should be used when handling intact tablets of hazardous medications such as finasteride. The DON confirmed that nurses are expected to wear gloves to minimize contact and protect themselves when handling these medications. This failure to adhere to established guidelines and facility policy had the potential to pose health risks to both staff and residents.
Lack of Documentation for Non-Narcotic Medication Destruction
Penalty
Summary
The facility failed to document the disposition and destruction of non-narcotic prescription medications for its residents. During an inspection of the medication room, a nurse was unable to locate any records of prescription drug destruction and was unsure about the procedures for storing or destroying discontinued non-narcotic medications. The medication room did not have a designated storage area for discontinued medications. The Director of Nursing confirmed that nurses were allowed to destroy discontinued prescription medications without any system of documentation or witnessed signatures, and there was no option to return unused drugs to the pharmacy. The Consultant Pharmacist stated she was only involved in the destruction of narcotic drugs and not non-narcotic medications, and indicated that the facility should follow its policy for discontinued drug disposition. A review of the facility's policy on discarding and destroying medications revealed that while it referenced compliance with federal, state, and local regulations for the disposal of non-hazardous pharmaceuticals and controlled substances, it did not address the need for documentation or accountability in the destruction of non-narcotic medications. This lack of documentation and clear procedures for non-narcotic medication destruction was observed in a facility with a resident census of 35.
Failure to Prevent Duplicate PPI Therapy in a Resident with GERD
Penalty
Summary
A deficiency occurred when a resident with a history of GERD, diabetes, kidney disease, and heart issues was prescribed and administered two proton pump inhibitors (PPIs), pantoprazole (Protonix) and omeprazole (Prilosec), at the same time. The resident's medical record showed that Prilosec had been prescribed for GERD and continued after a recent hospitalization, while Protonix was added upon the resident's return from the hospital. Nursing staff did not identify or address the duplicate therapy, and the duplicate medications were not flagged in the electronic medical record system. The Licensed Vocational Nurse acknowledged that Prilosec should have been discontinued and that the physician should have been notified about the duplicate PPI therapy. The facility's consultant pharmacist confirmed that there was no clinical justification for the resident to be on both PPIs simultaneously and that this practice would not provide additional benefit. The facility's policies required ongoing review of medication regimens for indications, doses, duration, and potential adverse consequences, but these procedures were not followed in this case. The medical director was not reached for comment during the survey.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9.52%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 43 opportunities involving three residents. In one instance, a nurse administered Robitussin DM, which contains both guaifenesin and dextromethorphan, instead of the prescribed plain Robitussin (guaifenesin only) to a resident with allergy and cough symptoms. The nurse could not locate the correct medication and used a similar product from another unit without clarifying the order with the physician. Another error involved the administration of a laxative containing only Senna to a resident, despite the physician's order specifying a combination of Senna and Docusate. The nurse attributed the mistake to the similar appearance of the medication bottles. In a third case, a nurse applied a lidocaine 4% patch to a resident for pain management, although the order specified a 5% strength patch. The nurse documented the administration as 5% on the Medication Administration Record. The facility's policy requires medications to be administered according to prescriber orders and verified for the correct resident, medication, and dosage, but these procedures were not followed in the observed cases.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of drugs and biologicals in both the medication room and the treatment cart. In the medication room, expired Covid-19 testing products and vaccines with unclear expiration dates were found. The Covid-19 vaccine syringes were stored in the refrigerator with labels that did not clearly indicate the beyond use date or when the product was thawed, and the storage instructions were inconsistent. Additionally, a plastic drawer contained expired swabs for throat infection and supplies for IV use, including items for residents no longer in the facility, co-mingled with other supplies. The treatment cart, located in the main hallway, contained multiple opened wound care products that were labeled as sterile and for one-time use only. These included opened sterile Iodoform Packing strips, non-adherent pads, calcium alginate dressings, and comfort foam dressings, all marked as sterile and not for reuse. Expired swabs for throat infection were also found in the cart's active storage area. These items were accessible in areas where they could be used for resident care. Interviews with the Director of Staff Development and the Director of Nursing confirmed the findings. The DON acknowledged the need for continuous re-organization of the small medication room and stated that monthly checks by nurses and the pharmacy consultant were not detailed enough to catch these issues in the active storage areas. Facility policies reviewed indicated requirements for safe, secure, and orderly storage of medications and supplies, as well as proper labeling and removal of outdated or deteriorated items.
Failure to Follow Policy for Storage and Discarding of Resident Food Brought by Family
Penalty
Summary
The facility failed to implement its policy regarding the storage and handling of food and beverages brought in by family or visitors for residents. Specifically, two frozen bottles of apple juice belonging to a resident were found stored in the staff refrigerator, rather than in the designated resident food refrigerator. One of the bottles was past its expiration date, and the other had no expiration date marked. According to the facility's policy, expired food or beverages should be discarded, and items without a manufacturer's expiration date should be dated upon arrival and discarded after three days if refrigerated or thirty days if frozen. The Director of Staff Development confirmed that the bottles belonged to the resident and acknowledged the improper storage and failure to discard the expired item. The resident involved had a regular diet order with thin liquids and had been admitted to the facility prior to the incident. The Director of Nursing also confirmed that the bottles should have been stored in the appropriate refrigerator and that the expired juice should have been discarded, as per facility policy. The improper storage and failure to discard the expired juice were identified during an observation and interview, and the deficiency was limited to this one resident among the sampled group.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Two resident rooms were found to be non-compliant with space requirements, as each room provided less than 80 square feet per resident. Specifically, one room measured 308.95 square feet and was occupied by four residents, resulting in 77.24 square feet per resident. Another room measured 288.4 square feet and was also occupied by four residents, giving each resident 72.1 square feet of living space. These measurements were confirmed during an observation and interview with the Maintenance Director, who stated that no residents in these rooms had complained about the room size or requested transfers. Interviews with residents and observations of care revealed that residents did not express concerns about the room size, and staff were able to provide necessary care and services without obstruction. There was sufficient space for movement, privacy, and storage of personal belongings, and no heavy equipment was present in the rooms that could interfere with care. Despite these observations, the rooms did not meet the required minimum square footage per resident.
Failure to Employ Qualified Nutrition Professional and Ensure Food Safety
Penalty
Summary
The facility failed to employ a qualified nutrition professional to manage the food and nutrition services. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis, and the Registered Dietitian (RD) worked part-time. This led to multiple issues, including the DSS not knowing the cool-down method for leftover meat sauce and Pozole soup, not ensuring time and temperature monitoring during the thawing of frozen food items, and not ensuring residents were served palatable food. Additionally, the DSS did not ensure food was fortified for residents on a fortified diet and did not ensure residents on a Consistent Carbohydrate (CCHO) diet received the correct diet. The DSS also failed to communicate to the RD that most residents did not like milk, resulting in the facility not providing a substitute of equal nutritive value. Furthermore, the DSS did not effectively maintain a system to ensure that residents' food preferences were accurately recorded on individual tray cards. During a kitchen observation, multiple unlabeled and undated food items, thawed and refrozen food items, and moldy tomatoes were found in the freezer and refrigerator. The DSS admitted that cooks were responsible for checking food items, but she should also be monitoring the refrigerator and freezer. The DSS was not present full-time and was also working in a neighboring facility. The RD confirmed that she worked only 8 hours a week in the facility. The facility's policy and procedure on sanitation and the DSS job description indicated that the DSS was responsible for instructing employees in food safety and sanitation and for monitoring food temperatures and cool-down logs. However, the DSS failed to provide documented staff training related to food safety. The facility's policy on meal service indicated that meals should be served at the appropriate temperature and that hot food should be at or above 140°F. However, during tray line observations, pureed foods were found to be runny and not holding their shape, and regular textured foods were served at temperatures below the recommended levels. Residents complained about receiving cold food, and the DSS admitted to providing education to kitchen staff but did not follow up. The RD was not aware of the residents' complaints about cold food. Additionally, the facility's policy on fortification of food was not followed, as residents on a fortified diet did not receive additional items to increase the nutrient content of the food served. The DSS also failed to ensure that residents on a CCHO diet received the correct diet, as regular desserts and bread portions were served instead of the diet versions. The DSS did not communicate with the RD about residents' preferences for milk, resulting in no substitutions being made. The DSS also failed to maintain accurate resident profile cards, leading to incorrect food preferences being recorded and outdated profile cards being used.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure food and nutrition staff had the appropriate competencies and skills set, leading to several deficiencies. Staff did not follow the correct procedure for thawing frozen food items. During observations, it was noted that frozen meat was being thawed inappropriately without time or temperature monitoring, which is against the 2022 Federal Food Code. This improper thawing process was acknowledged by the staff, who admitted there was no oversight of temperature monitoring to ensure food safety. Additionally, staff demonstrated a lack of knowledge in checking the sanitizer strength used for the dish machine, using the incorrect sanitizer strip initially. Furthermore, the dish wash machine temperature was recorded inaccurately, with logs showing the same temperature for multiple cycles on multiple days, even before the lunch service had begun. The facility's policies and job descriptions indicated that staff should be trained and knowledgeable in these areas, but the surveyor found no documented staff training related to food safety.
Failure to Provide Margarine as Per Menu
Penalty
Summary
The facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order were not served with one teaspoon of margarine at lunch. This was observed during a lunch tray line observation, where no margarine was served on any resident lunch tray, including those of the nine affected residents. The facility's Winter Menus indicated that one teaspoon of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. Additionally, the facility's policy and procedure titled 'Diet Orders' stated that diet orders as prescribed by the physician would be provided by the Food & Nutrition Services Department. This failure had the potential for residents to receive and/or consume inadequate caloric intake.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. Resident 1 reported that meals were often cold and not palatable, and the same menu was served repeatedly. The Minimum Data Set (MDS) indicated Resident 1 was cognitively intact and had hypothyroidism. Resident council meetings also documented complaints about cold food and repetitive menus. The Activity Director confirmed that residents had complained about cold food and dietary issues, which were reported to the Dietary Supervisor. The Dietary Services Supervisor acknowledged awareness of the complaints but did not follow up on food temperature checks. During a tray line observation, the Registered Dietitian (RD) measured food temperatures and found them below the required 141°F. The pureed and regular textured food on a resident's tray was also below the recommended temperature, with the pureed fish at 121.8°F, pureed broccoli at 119.3°F, and pureed risotto at 106.5°F. The kitchen lacked equipment to hold food hot during tray line service. The RD sampled the food and found it cold, bland, and with a sticky texture. The facility's policy indicated that hot food should be served at or above 140°F, but this standard was not met. The facility's Diet Manual also specified that pureed food should be smooth and moist, which was not the case in this instance.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve foods in a sanitary manner, leading to potential foodborne illness risks. Observations revealed that the cool down method was not performed for leftover meat sauce and Pozole soup in the refrigerator, and the Cool Down Log had no entries. The Dietary Services Supervisor (DSS) admitted that no temperature monitoring was completed during the cool down process because the meat was mixed with other ingredients. The facility's policy required proper documentation and temperature monitoring during the cooling process, which was not followed. Frozen food items were incorrectly thawed and refrozen without proper time and temperature monitoring. Cook 1 and Cook 2 admitted to thawing frozen meat under running water and then refreezing it without documentation. The facility's policy required thawing meat in the refrigerator and monitoring the temperature to ensure it did not remain in the danger zone for more than four hours. Additionally, a box of cherry tomatoes in the refrigerator was found covered with white fuzzy material and dark spots, indicating spoilage. The DSS acknowledged that the tomatoes were past their shelf life and should have been discarded. Other deficiencies included storing a bag of cooked chicken together with frozen raw meat and poultry, multiple unlabeled and undated food items in the freezer, and improper handling of drinkware by staff. The ice machine was also found to have black build-up residue and white mineral build-up, and the cleaning and sanitizing procedures were not followed according to the manufacturer's instructions. The Maintenance staff admitted to using an unapproved cleaner and not following the detailed cleaning steps provided by the ice machine manufacturer. These failures had the potential to expose residents to foodborne illness.
Failure to Provide Adequate Supervision and Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and implement appropriate interventions for a resident who had repeated unwitnessed falls. Resident 16, who had a history of stroke and Non-Alzheimer's Dementia, required extensive assistance and one-person physical assistance for transfers and movements. Despite being identified as high risk for falls, the facility did not provide necessary supervision or alert devices to prevent unassisted transfers. This led to multiple incidents where Resident 16 was found on the floor after attempting to transfer without assistance, including falls in the dining/activity room, hallways, and his room. Observations and interviews revealed that Resident 16 was often left unsupervised and without necessary safety equipment, such as cushions or alert devices, to prevent falls. The care plan indicated the need for stand-by assistance during transfers, but this was not consistently implemented. The facility's policy on managing fall risks was not adequately followed, as evidenced by the repeated falls and lack of effective interventions to address Resident 16's specific needs. The Director of Nursing acknowledged concerns about the resident's repeated falls, but appropriate measures were not in place to prevent them.
Inappropriate Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the appropriate consistency for six out of 30 residents. During tray line observations on two consecutive days, pureed chili and cornbread were found to be too thin, resembling thickened cream soup and thin pudding, respectively. Similarly, pureed beef roast and zesty spinach were observed to be runny and spread out on the plate. A review of the Diet Type Report confirmed that six residents were on a pureed diet order. According to the facility's Registered Dietician's manual, pureed food should be smooth, moist, and able to hold its shape, which was not adhered to in these instances.
Failure to Provide Substitutes and Maintain Accurate Food Preferences
Penalty
Summary
The facility failed to offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided for all diets. During tray line observations, it was noted that over 20 trays did not include milk, despite it being listed on the winter menus. The Dietary Services Supervisor (DSS) stated that most residents do not like milk for lunch and other meals, and no substitution was made when milk was not provided. The Registered Dietitian (RD) was unaware of this issue and did not ensure a substitution was provided when residents preferred not to drink milk as per the planned menu. Additionally, the facility did not effectively maintain a system to ensure residents' food preferences were accurately recorded on their individual tray cards. One resident reported receiving cold food and being lactose intolerant, yet her preferences were not accurately reflected on her tray card. The DSS demonstrated that the facility's administrative documents, including resident profile cards, were not maintained within the licensed building and were outdated. A review of the resident profile cards showed multiple inaccuracies and missing information regarding food preferences and dislikes. The facility's policy indicated that the Food and Nutrition Services Director or designated personnel should update the profile cards, but this was not being done accurately or consistently.
Failure to Provide Physician-Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide physician-prescribed therapeutic diets to residents, as observed during multiple lunch tray line observations. Six residents on a Fortified diet did not receive supplemental food items such as margarine and extra gravy as ordered. Additionally, three residents on a Consistent Carbohydrate diet received regular diet items instead of the modified versions specified in their diet orders, such as Diet Citrus Chiffon Delight and half portions of cornbread and garlic sticks. One resident with a diet order for extra protein did not receive the additional meat as prescribed. During the observations, it was noted that the lunch trays for residents on therapeutic diets were identical to those on regular diets, lacking the necessary modifications. The facility's Winter Menus and recipes indicated specific changes for therapeutic diets, but these were not followed. For example, residents on a CCHO diet were supposed to receive diet gelatin and omit brown sugar from desserts, but these modifications were not made. The facility's policy and procedure documents also outlined the requirements for fortifying food to increase calorie and protein intake, which were not adhered to. The deficiencies were confirmed through interviews with the facility's cooks, who admitted to not preparing separate diet desserts and using regular recipes for all residents. The facility's policies clearly stated that diet orders prescribed by physicians should be provided by the Food & Nutrition Services Department, but this was not implemented, leading to potential risks for the residents involved.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for three residents (Residents 5, 13, and 16) on four separate days in February 2024. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) did not document the administration of multiple medications, including those for high blood pressure, high blood sugar, depression, and blood clot prevention. The missing entries were identified during a review of the Medication Administration Records (MARs) for the specified dates. Both the DON and LVN 3 admitted to administering the medications but failing to document them due to being too busy and, in the case of LVN 3, falling ill and forgetting to document upon return to work. The lack of documentation was confirmed during interviews and record reviews with both the DON and LVN 3. The DON acknowledged that the expectation was for medications to be charted immediately after administration. The failure to document these medications could lead to unnecessary duplication of medication administration and hinder accurate analysis of the medications' effectiveness. The report references a nursing textbook that emphasizes the importance of recording each dose of medication as soon as possible after it is given, as the medication record is a legal document.
Dishwashing Machine Temperature Maintenance Failure
Penalty
Summary
The facility failed to ensure that the dishwashing machine maintained the manufacturer's recommended water temperature range during the wash and rinse cycles. During an observation, the dishwashing machine's water temperature gauge reached a maximum of 106 degrees Fahrenheit during both the wash and rinse cycles, which is below the required minimum of 120 degrees Fahrenheit. Dietary Aide 2 recorded incorrect temperatures in the Dish Machine Temperature Log, indicating that the machine was operating within the required range when it was not. A subsequent test with a water-proof digital holding thermometer showed a maximum temperature of 147.8 degrees Fahrenheit and a minimum of 74 degrees Fahrenheit, further confirming the inconsistency in temperature maintenance. The facility's policy and procedure on sanitation, as well as the dishwashing machine manufacturer guidelines, were not adhered to, as the equipment was not maintained in proper working order. The failure to maintain the correct water temperatures during the dishwashing cycles had the potential to result in insufficient sanitization of dishware, posing a risk of foodborne illness to residents. The deficiency was identified through a combination of observation, interview, and record review, highlighting a significant lapse in the facility's adherence to sanitation standards.
Failure to Complete Baseline Care Plans and Provide Summaries
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents (Residents 187, 185, and 188) and did not provide them or their representatives with a summary of the baseline care plan. Resident 187, who was admitted with hemiplegia and hemiparesis, was discharged without a baseline care plan. The Director of Nursing (DON) confirmed that the baseline care plan was not developed within the required timeframe. Resident 185, admitted with streptococcal arthritis, stated in the presence of family members that he did not receive a written summary of his baseline care plan, despite the care plan indicating that a copy would be given to the resident. Resident 188, admitted for surgical aftercare following nervous system surgery, also did not receive a copy of the baseline care plan, as confirmed by the DON. The facility's policy and procedures (P&P) titled 'Care Plan - Baseline,' revised in March 2022, indicated that a baseline plan of care should be developed within 48 hours of admission to meet the resident's immediate health and safety needs. The P&P also stated that a written summary of the baseline care plan should be provided to the resident or their representative in a language they can understand, and this provision should be documented in the medical records. The DON acknowledged that the interdisciplinary team members did not complete the baseline care plans within the required timeframe and that summaries were not provided to the residents or their representatives.
Failure to Implement Care Plan for Resident at Risk of Aspiration
Penalty
Summary
The facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure for Resident 6, who was at risk of aspiration due to dysphagia. Despite a physician's order for the use of a provale cup to prevent choking and aspiration pneumonia, the staff stopped using the specialized cup because Resident 6 found it frustrating. Instead, Resident 6 was given a regular plastic cup, which led to frequent coughing during meals. This change was not communicated to the speech therapist, nor was a speech evaluation conducted. Additionally, there were no active care plans addressing Resident 6's risk of aspiration and dysphagia diagnosis. Observations and interviews revealed that Resident 6, who had poor cognition and a history of swallowing disorders, was repeatedly coughing when fed certain foods and liquids. The Director of Nursing acknowledged that Resident 6 was at high risk for aspiration but did not take appropriate steps to mitigate this risk. The facility's policy required a comprehensive, person-centered care plan to be developed within seven days of the MDS assessment and no more than 21 days after admission, but this was not done for Resident 6.
Failure to Assess Severe Weight Loss in Resident
Penalty
Summary
The facility failed to assess a resident (Resident 16) who experienced severe weight loss. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, dementia, dysphagia, depressive disorder, and an acquired absence of the digestive tract, showed a significant weight loss of 21 pounds (11%) over six months and 8 pounds in one month. Despite these changes, the last nutrition-related documentation by a Registered Dietitian (RD) was a Quarterly Nutrition assessment and a Progress Note dated several months prior. The care plan related to weight loss was last revised over a month before the most recent weight loss was recorded. The Minimum Data Set (MDS) indicated that the resident had severe cognitive impairment and had experienced significant weight loss without being on a physician-prescribed weight-loss regimen. Interviews with facility staff, including the Licensed Vocational Nurse (LVN) MDS Coordinator and the Director of Nursing (DON), revealed that the RD was responsible for filling out the MDS section related to weight loss. The DON stated that when unplanned weight loss was identified, the RD was supposed to conduct an assessment and present it to the Interdisciplinary Team (IDT) for discussion and intervention planning. However, this process was not followed in the case of Resident 16, leading to a failure in timely assessment and intervention for the resident's severe weight loss.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs when psychotropic medications were administered without adequate clinical indication and monitoring. Resident 2 was administered Ziprasidone HCL for dementia and depression without adequate monitoring of target behaviors. Despite being calm and cooperative, Resident 2 continued to receive the medication without documented behavioral symptoms or side effect monitoring. The Consultant Pharmacist had recommended a gradual dose reduction, but this was not implemented, and there was no documentation of target behavior monitoring in the Medication Administration Record (MAR) for January and February 2024. Resident 16 was administered Zyprexa for altered sensorium and aggressive behaviors, and Trazodone for sleep without adequate monitoring of hours of sleep. Additionally, Resident 16 received PRN Lorazepam for anxiety and aggressive behavior without the implementation of non-pharmacological interventions first. The PRN Lorazepam was extended beyond 14 days without physician documentation of the clinical rationale for continued use. Despite the Consultant Pharmacist's recommendation to update the Zyprexa order to include indication and to review PRN psychotropic medications every 14 days, these actions were not taken. Interviews with staff revealed that both residents were calm and cooperative, contradicting the need for continued use of these medications. The Director of Nursing (DON) acknowledged that non-pharmacological interventions should be offered before administering PRN psychotropic medications and that the hours of sleep for Resident 16 were not monitored. The facility's policy indicated that psychotropic medications should not be prescribed or given on a PRN basis unless necessary to treat a diagnosed specific condition, and PRN orders should be limited to 14 days unless otherwise documented by the physician.
Failure to Use Assistive Device and Consult Speech Therapist
Penalty
Summary
The facility failed to consider alternative recommendations for the use of the provale cup assistive device for a resident identified at risk for aspiration. Despite the resident's refusal to use the provale cup, which was prescribed to help prevent choking by delivering a measured amount of liquid, the staff did not consult with the Speech Therapist for alternative recommendations. This resulted in the resident being given water from a plain plastic cup, leading to frequent coughing during meals. The resident had a history of dysphagia and was diagnosed with Non-Alzheimer's Dementia, which further increased the risk of aspiration. During observations, the resident was seen coughing repeatedly when fed corn bread and salad, and the Restorative Nursing Assistant provided water from a regular plastic cup. Interviews with the Director of Nursing and the Speech Therapist revealed that the Speech Therapist was not informed of the resident's refusal to use the provale cup, and no re-evaluation was conducted. The resident's Minimum Data Set indicated poor cognition and a swallowing disorder, highlighting the need for appropriate assistive devices and consultation with specialists to prevent aspiration and potential pneumonia.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility had two resident rooms with multiple beds that provided less than the required 80 square feet per resident. Room [ROOM NUMBER] measured 280 square feet, equating to 70 square feet per resident, and room [ROOM NUMBER] measured 286.6 square feet, equating to 71.65 square feet per resident. During observations and interviews, staff members, including CNAs, stated that there was enough space to provide care and no issues with maneuvering necessary care equipment. Residents also reported having adequate space for their belongings and no concerns about room space. Despite these statements, the rooms did not meet the regulatory space requirements, which could potentially result in inadequate space for care delivery and storage of residents' belongings. No negative consequences were observed due to the decreased space in the two rooms, and a room size waiver was recommended.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
