Bakersfield Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 6212 Tudor Way, Bakersfield, California 93306
- CMS Provider Number
- 555260
- Inspections on file
- 60
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Bakersfield Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain functional Hoyer lift equipment and appropriate maintenance records. One of two Hoyer lift battery chargers in the charging station was not charging batteries, and two cognitively intact residents reported past episodes where the Hoyer lift stopped working due to dead batteries while they were suspended in full body slings, one in bed and one in a wheelchair. The Maintenance Supervisor acknowledged that no maintenance logs or work orders were kept for the Hoyer lifts, and the Administrator was unaware of any official P&P specific to the Hoyer lift or an owner’s manual for the batteries, despite a facility policy requiring charged batteries and a maintenance policy assigning responsibility for keeping equipment safe and operable.
Three cognitively intact residents who required extensive or maximal assistance with ADLs, toileting, and transfers reported prolonged call light response times, ranging from 20–30 minutes to as long as an hour and a half, when requesting help such as urinal emptying, getting out of bed, breathing treatments, ice, and incontinence care. One resident described feeling terrible and shaky when not assisted out of bed at his preferred time, another became angry and sometimes went to the nurse’s station where staff were observed sitting, and a third felt frustrated after waiting up to an hour. CNAs reported feeling rushed and caring for 15–23 residents when short staffed, and one did not take scheduled breaks, while the facility’s Resident Rights policy required staff to treat residents with kindness, respect, and dignity and to assist them in exercising their rights.
Two residents with intact cognition experienced failures in timely and accurate medication administration. One resident with chronic pain had a scheduled dose of topical Diclofenac gel given more than three hours past the ordered time. Another resident reported delays in receiving breathing treatments and not receiving a stomach medication; MAR review showed that both a scheduled Ipratropium/Albuterol nebulizer treatment and a Pantoprazole dose were not documented as administered at a scheduled time, contrary to facility policy requiring medications to be given within one hour of the prescribed time and fully documented.
A cognitively intact, blind resident was unable to make and receive private phone calls after in-room landlines were removed and the facility declined to allow installation of a private landline at the resident’s expense. The resident relied on a voice-controlled device that only allowed outgoing calls on speaker, eliminating privacy, and reported that a previously available cordless phone was no longer working. Staff described routing calls through the nurse’s station and inconsistently referenced portable phones for privacy, while family members reported they could no longer directly reach the resident, often encountering unanswered or busy lines and having to wait for return calls on speaker. These actions and inactions conflicted with facility policies guaranteeing residents easy access to telephones and the right to use a telephone in privacy.
A resident who shared a room with another resident diagnosed with head lice did not have a care plan developed to address her risk of contracting lice. The at-risk resident was later found to have live lice and received treatment, but there was no documentation of ongoing monitoring for lice or related symptoms as required by facility policy.
Two residents experienced significant delays in call light response, with one waiting up to an hour for toileting assistance and another waiting up to 45 minutes for a breathing treatment, both relying on staff for essential care. Staff interviews confirmed frequent short staffing, leading to high resident assignments for CNAs and LVNs, missed care tasks, and inability to provide timely responses to resident needs.
A CNA's employee file lacked documentation of completed skills competency verification, as confirmed by the Administrator during record review. Facility policy requires all nursing staff to meet competency requirements and demonstrate ability to identify, document, and report resident changes of condition, but this was not documented for the CNA.
A resident with dementia and major depressive disorder had a psychotropic medication discontinued by the IDT without notifying the responsible party or hospice provider, as required by facility policy. This omission resulted in the RP and hospice not being included in the care planning and decision-making process.
A resident requested copies of their medical records, but the facility did not provide the records within the two business days required by its policy. Instead, the records were sent 15 days after the request, resulting in a violation of the resident's rights.
A resident who required substantial assistance for toileting experienced a 40-minute delay in call light response, resulting in incontinence and emotional distress. Staff interviews confirmed frequent short staffing, with CNAs assigned to care for up to 24 residents per shift and unable to respond to call lights promptly, leading to unmet resident needs.
A resident with a history of fluid overload was still marked as being on a fluid restriction, as indicated by a green sticker on the door and an outdated care plan, even though the fluid restriction order had been discontinued months earlier. The care plan was not updated to reflect the change, contrary to facility policy requiring accurate clinical records.
A resident with a history of constipation and recent episodes of diarrhea did not have Docusate Sodium held as ordered during loose stools, and was not administered Imodium or Loperamide as prescribed for diarrhea. The DON confirmed that medications were not given or withheld according to physician orders, contrary to facility policy.
A resident did not receive prescribed doses of Apixaban and Metoprolol at the scheduled time due to the medications not being available in the medication cart, resulting in a delay of several hours before administration. The nurse on duty confirmed the delay and that the facility's policy requiring medications to be given within one hour of the scheduled time was not followed. The DON also acknowledged the deviation from both physician orders and facility policy.
A resident reported feeling uncomfortable and unsafe after an LVN entered her room and kissed her. The incident was not reported to the appropriate authorities in a timely manner, as required by the facility's policy. The delay in reporting led to the resident experiencing increased anxiety, for which she was prescribed medication.
A resident with severely impaired cognition was not protected from physical and verbal abuse by another resident. Despite witnessing verbal abuse and reporting it to an LVN, no intervention occurred, leading to a subsequent physical assault. The facility's abuse prevention policy was not followed, as no protective measures were taken.
The facility failed to report a resident-to-resident physical abuse incident to the CDPH and local ombudsman within the required timeframe and did not conduct a thorough investigation. The DON confirmed the incident but did not provide evidence of timely reporting, and the investigation was limited to a few interviews, contrary to the facility's policy.
The facility failed to implement IDT recommendations for monitoring two residents involved in a physical altercation. Despite the IDT's advice to monitor for mood changes and delayed injury symptoms, no documentation of such monitoring was found for several days. This oversight contravenes the facility's policy on comprehensive, person-centered care plans, which require regular updates and monitoring following significant changes in a resident's condition.
The facility failed to follow its policy for documenting resident assessments after a verbal altercation involving a resident who threatened others. The DON confirmed that the LVN did not document initial assessments for the involved residents, violating the facility's policy requiring nurses to record changes in residents' conditions.
The facility failed to provide sufficient staffing, resulting in delayed call light response times for three residents. A resident reported wait times of 30 to 45 minutes, with the worst being two hours, while another experienced one and a half to two-hour delays. CNAs felt rushed, caring for up to 16 residents due to staff call-outs, which occurred one to two times a week. The facility's staffing policy was not met, leading to increased wait times for residents' basic needs.
The facility failed to administer and document treatments as prescribed for two residents, leading to potential risks of worsening skin conditions and infections. The Treatment Administration Records (TAR) showed multiple instances where treatments for moisture-associated skin damage and a fungal infection were not documented as administered. The Director of Nursing confirmed the missing documentation, indicating a failure to adhere to professional standards of quality care.
A resident with severe cognitive impairment and multiple health conditions developed a facility-acquired pressure ulcer due to the LTC facility's failure to follow its pressure injury prevention policy. The resident's skin condition was not regularly assessed or documented, and there was a lack of communication with the physician. The resident experienced pain, and the ulcer required further medical evaluation.
The facility failed to implement proper infection control practices, including a treatment nurse with long artificial nails, a frayed linen cart cover, housekeeping carts without lids, and lack of PPE in rooms on Enhanced Barrier Precautions. These deficiencies were confirmed by the Infection Preventionist Nurse and contradicted facility policies.
The facility did not follow its policy on Advance Directives for three residents, failing to document whether assistance was offered, accepted, or declined. The current form lacks a section for this documentation, and the Director of Admissions confirmed the absence of a process to ensure compliance with the policy.
A resident was prescribed psychotropic medications for depression and anxiety without documented informed consent, contrary to the facility's policy. The resident reported not being included in the decision-making process for these medications, and a review confirmed the absence of required consent forms.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a bed-bound resident while assisting with meals. The CNA acknowledged the inappropriate action, which contradicted the facility's policy requiring staff to assist residents with meals in a manner that ensures safety, comfort, and dignity. This oversight had the potential to negatively impact the resident's emotions, behavior, and social needs.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their psychosocial and physical needs. One resident's call light was clipped to a curtain, making it unreachable, while another's was on the floor. Both residents required assistance with daily activities, and their care plans emphasized the importance of accessible call lights.
A facility failed to inventory and document a resident's personal belongings upon admission, as required by their policy. The resident reported missing clothing items, but the Personal Belonging Inventory Checklist was blank, and no inventory sheet was found in the medical records. The Social Services Director confirmed that the inventory should have been conducted and documented.
A resident experienced significant weight loss over several months, but the facility failed to complete a change of condition assessment and notify the physician. Despite documented weight loss percentages indicating a significant change, there was no record of physician notification, contrary to the facility's policy.
The facility failed to provide individualized activities care plans for two residents, as required by its policy. During a review, it was found that neither resident had a care plan for preferred activities and interests, potentially leading to unmet psychosocial needs. The Director of Activities confirmed the absence of these care plans, which are necessary for residents to engage in activities of their choice.
A resident with significant hearing loss was not assisted by the facility in obtaining hearing aids, despite being eligible under their Medicare Plan. The resident and their spouse reported communication difficulties, and the facility's policy required staff to help residents with sensory impairments. The Social Services Director noted that the audiology company used by the facility did not work with the resident's Medicare Plan, and this issue was not addressed in a timely manner.
A facility failed to provide timely podiatry services for a diabetic resident with overgrown toenails, despite an active order for a podiatry consult. The resident's feet were observed to have long, thick, and yellowing nails with dry, scaly skin. The facility's policy requires diabetic residents to be referred to a podiatrist, but this was not done in a timely manner, potentially exposing the resident to complications.
A resident experienced frustration and emotional distress due to the facility's failure to assist her in changing her Power of Attorney (POA) from her brother, who controlled her finances. Despite expressing her desire to change her POA during interdisciplinary team conferences, the Social Services Assistant and Director did not take action to address her concerns. The facility also lacked a policy for handling POA changes.
A facility failed to follow its policy on controlled medications, resulting in a missing Hydrocodone tablet for a resident. The DON did not properly account for medications before disposal, and the CMDL lacked a signature of receipt. The facility's policy requires discrepancies to be reported and reviewed, but this was not followed, leading to potential drug diversion.
A facility failed to follow its medication storage policy when two expired Daptomycin IV solutions were found in the medication storage room. The DON confirmed that the expired medications should not have been stored there and admitted there was no surveillance process for outdated medications. The facility's policy required immediate removal and disposal of outdated medications, but this was not implemented, posing a risk to a resident.
A resident experienced significant weight loss due to ill-fitting dentures, with a dental referral made in early July but not addressed until late October. The resident's weight dropped from 139 to 129.6 pounds over two months, with no RD assessment for the July weight loss. The facility's policy required timely dental services, but the delay potentially worsened the resident's eating difficulties.
A resident received topical medication without a physician's order by unlicensed staff, as CNAs applied ointments to the resident's abdominal folds without proper documentation or authorization. The facility's policy states that only licensed individuals may administer medications, and all treatments must be recorded, which was not followed in this case.
A facility failed to document the administration of Cefepime for a resident with MRSA, resulting in an incomplete MAR. The resident had a PICC line and was prescribed the antibiotic for a wound infection. The DON confirmed the lack of documentation on four occasions, which violated the facility's medication administration policy.
A facility failed to follow a physician's orders for a resident's cellulitis treatment, missing documentation of treatments on several days. The prescribed care involved cleansing, applying medication creams, and wrapping the affected area, which was not done as required. The DON confirmed the treatments were not administered on those days.
The facility failed to implement an effective pest control program, as evidenced by the presence of cockroaches in the staff break room. Observations and staff interviews confirmed multiple sightings of cockroaches, with no specific pest control inspections documented for the break room. The Director of Maintenance was unaware of the issue due to a lack of reports.
Two residents reported that their call lights were not answered timely, with delays of up to an hour. Both residents require assistance with transfers and have a BIMS score indicating cognitive intactness. The facility's policy requires prompt response to call lights, but ongoing issues, especially during night shifts, were noted in Resident Council meetings.
A resident reported being grabbed by a caregiver, resulting in a purple discoloration on the arm. The facility failed to investigate the alleged abuse within the required five working days, as confirmed by the DON and a review of the facility's policy. Nine working days after the incident, there was no documentation of the investigation summary.
The facility failed to respond to call lights in a timely manner for four residents, impacting their ability to receive necessary assistance with ADLs. Residents reported waiting from 15 minutes to two hours for help, despite facility policy requiring prompt responses. A CNA noted staffing shortages as a contributing factor.
The facility failed to ensure that three residents received necessary bathing assistance, resulting in inadequate cleanliness and potential infection risks. Frequent short staffing led to missed showers and improper documentation, with residents reporting changes in their shower schedules and inadequate care.
The facility failed to provide sufficient staffing, resulting in significant delays in answering call lights for eight residents. Residents reported waiting times of up to two hours for essential needs, and CNAs confirmed frequent short staffing and ignored call lights. This failure violated the facility's policy on staffing and resident rights, causing distress and potential harm to the residents.
The facility failed to offer a bed hold notice to a resident during a hospital transfer. Upon return, the resident found personal items and medical equipment moved, and another resident in the bed. The DON confirmed the bed hold policy was not followed.
The facility failed to ensure that three LVNs were competent in the application and operation of a BIPAP machine, leading to an incident where a resident choked and coughed due to incorrect application. The DON confirmed that the LVNs lacked the necessary skills, despite the facility's policy requiring competent staff.
The facility failed to ensure that four out of five sampled employees had the required criminal background checks or reference checks completed before their hire dates, potentially exposing residents to abuse.
The facility failed to implement its hand hygiene policy, as observed with a CNA, a TA, and a HSK not performing hand hygiene after resident contact and PPE removal. This occurred while multiple residents and staff were positive for COVID-19.
Failure to Maintain Functional Hoyer Lift Equipment and Maintenance Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure essential Hoyer lift equipment and related maintenance systems were functioning properly. One of two Hoyer lift battery chargers in the designated charging station was observed not charging the Hoyer lift battery, despite power reaching the charging port. Two cognitively intact residents, each with a BIMS score of 15 on their respective MDS assessments, reported prior incidents in which the Hoyer lift stopped working due to dead batteries while they were in full body slings—one while in bed and the other while in a wheelchair. The facility’s existing policy on using mechanical lifting machines required staff to make sure the battery is charged before use. The facility also lacked appropriate maintenance oversight and documentation for the Hoyer lifts and their batteries. The Maintenance Supervisor stated that no maintenance log was kept for the Hoyer lifts and that work orders were not being submitted for these devices. The Administrator reported not knowing whether there was an official P&P for the Hoyer lift and confirmed there was no owner’s manual for the Hoyer lift batteries, and he was not aware of any maintenance logs. This was inconsistent with the facility’s Maintenance Service policy, which assigned responsibility to the maintenance department and director to maintain equipment in a safe and operable manner and to develop and maintain a schedule of maintenance service.
Untimely Call Light Response for Residents Requiring Extensive Assistance
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for three cognitively intact residents who required extensive assistance with ADLs and mobility. One resident, who was dependent for sit-to-stand and bed-to-chair transfers and required extensive assistance with dressing, toileting, and transfers using a Hoyer lift, reported using the call light to have his urinal emptied and to get in and out of bed. He stated that call lights could take from 30 minutes to an hour and a half to be answered and that he preferred to get up at 6 a.m. but was sometimes not assisted out of bed until 8 a.m., which made him feel terrible and shaky because he wanted to get up. Another resident, with a BIMS score indicating intact cognition, reported using the call light to request breathing treatments and stated he typically waited 20–30 minutes for staff to respond. If no one responded within that time, he would go to the nurse’s station himself, where he observed nurses and CNAs sitting at the station, and he stated that the wait time made him feel angry. A third resident, also cognitively intact and requiring substantial/maximal assistance for toileting hygiene and transfers with a mechanical lift, reported using the call light to request ice and incontinence care. This resident stated that the worst wait time for a call light response was up to an hour, which made him feel frustrated. His care plan included interventions such as two-person extensive assistance for toileting, two-person total assistance with a mechanical lift for transfers, and offering toileting on rounds, upon request, and as needed. CNAs interviewed on the night shift reported feeling rushed and hurried, with one CNA assigned 15–17 residents and another 18–23 residents when the facility was short staffed, and one CNA stated she did not take her ten-minute breaks. The facility’s Resident Rights policy required employees to treat residents with kindness, respect, and dignity and to assist each resident in exercising their rights, but residents’ reports of prolonged call light response times and associated negative feelings demonstrated that this was not consistently achieved.
Failure to Administer and Document Medications Timely and as Ordered
Penalty
Summary
The facility failed to ensure medications were administered timely and in accordance with professional standards for two cognitively intact residents. One resident, with a Brief Interview for Mental Status (BIMS) score of 15 and chronic pain in the arm and leg, reported that medications were sometimes given on time and sometimes not, and that waiting for medications worsened the pain. Review of this resident’s physician orders dated 7/5/24 showed an order for Diclofenac Sodium 1% topical gel to be applied to the shoulders twice daily for chronic pain. Review of the Medication Administration Record (MAR) for February 2026, confirmed by the Director of Nursing (DON), showed that on 2/11/26 the 5 p.m. dose of Diclofenac gel was documented as administered at 8:17 p.m., which was 3 hours and 17 minutes after the scheduled administration time, outside the facility’s policy requirement that medications be administered within one hour of the prescribed time. A second resident, also with a BIMS score of 15, reported using the call light to request breathing treatments and having to wait 20–30 minutes before going to the nurse’s station. This resident further stated that a stomach medication was not received about a week prior, despite informing the nurse. Review of this resident’s MAR for February 2026 with the DON showed an order for Ipratropium/Albuterol 3 ml via nebulizer four times daily for shortness of breath or wheezing, with a start date of 7/26/25, and an order for Pantoprazole 40 mg delayed-release tablet by mouth once daily at 6 a.m. for esophagitis, with a start date of 1/24/26. On 2/18/26 at the 6 a.m. administration time, both the Ipratropium/Albuterol and Pantoprazole doses were left blank on the MAR, indicating they were not documented as administered, contrary to the facility’s medication administration policy requiring safe, timely administration as prescribed and documentation of the date and time medications are given.
Failure to Ensure Private and Accessible Telephone Use for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact, blind resident had reasonable access to and privacy in the use of telephones, as required by resident rights and the facility’s own policies. The resident, who had a BIMS score of 15 and had lived in the facility for about six years, reported that landline phones were removed from resident rooms approximately six months prior and that the facility would not allow installation of a private landline in his room, despite policy stating residents may have private telephone lines at their own expense. The resident stated he could not use a cell phone due to blindness and instead relied on a personal voice-controlled device to make calls, which required use of speaker mode and did not allow him to receive incoming calls, eliminating privacy. He also reported that a previously available portable phone was no longer working and not available for his use. Staff interviews showed inconsistent and inadequate practices for providing private phone access. CNAs and the receptionist/hospitality staff indicated that residents generally make and receive calls at the nurse’s station, and that staff either bring residents to the nurse’s station or transfer calls there. One CNA and the receptionist stated that portable phones were available for private calls, but the resident and family members reported that staff had said the cordless phone was no longer available or not working. Family members stated they previously called the resident daily but now could not directly reach him; instead, they encountered busy signals, unanswered calls, or had to leave messages so the resident could call them back using his voice-controlled device on speaker, without privacy. The administrator confirmed the facility had upgraded the phone system and that replacing in-room phone lines would require opening walls, but there was no indication that alternative arrangements ensured the resident’s right to private telephone use, contrary to the facility’s Resident Rights and Telephones policies.
Failure to Develop and Implement Care Plan for Resident at Risk of Head Lice
Penalty
Summary
The facility failed to develop a care plan for a resident who was at risk for contracting head lice after her roommate was diagnosed with head lice. On review of records, it was found that when the first resident was observed with head lice, there was no care plan created for the second resident, who shared the room and was therefore at risk. The Infection Preventionist confirmed that a care plan should have been developed for the at-risk resident due to her close contact with the affected roommate, but this was not done. Further review showed that the at-risk resident was later found to have live head lice and received treatment. However, there was no documentation that she was monitored for head lice after the initial assessment and treatment. The Infection Preventionist stated that the resident should have been monitored every shift for signs of itching and for the presence of lice or nits, but the absence of documentation indicated that this monitoring did not occur. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, which was not implemented in this case.
Delayed Call Light Response Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two of five sampled residents. One resident, who is cognitively intact and dependent on staff for toileting and hygiene, reported using the call light for assistance with water and changing, and stated that the shortest wait time experienced was 30 minutes, with waits extending up to an hour. This resident expressed dissatisfaction with the wait times, indicating a desire to leave the facility. Review of the resident's care plan confirmed the need for assistance and the intervention to encourage use of the call light. Another resident, also cognitively intact and at risk for ADL/mobility decline, reported waiting up to 45 minutes for a breathing treatment after using the call light, leading the resident to go directly to the nurses' station for assistance. This resident's care plan included interventions for respiratory care and medication administration as ordered. Staff interviews revealed that CNAs and LVNs were frequently assigned high numbers of residents, especially during staff call-offs, with CNAs caring for up to 18 residents and LVNs for up to 32 residents per shift. Staff reported that short staffing occurred multiple times per week, making it difficult to meet resident care needs and resulting in missed showers and breaks. The facility's policy and procedure for call lights was requested but not provided during the survey.
Failure to Verify CNA Skills Competency
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) possessed the necessary skills and abilities to provide adequate nursing care to residents. During an interview and review of employee records with the Administrator, it was found that the CNA's skills competency checklist had not been completed, despite the CNA having signed the job description and having a documented performance objectives form. The Administrator confirmed that there was no evidence of completed skills competency verification for the CNA. Review of the facility's policy indicated that all nursing staff are required to meet specific competency requirements and demonstrate competency in identifying, documenting, and reporting resident changes of condition, but this was not documented for the CNA in question.
Failure to Notify Responsible Party and Hospice of Psychotropic Medication Discontinuation
Penalty
Summary
The facility failed to notify the responsible party (RP) and hospice provider when a psychotherapeutic medication, Quetiapine, was discontinued for a resident with diagnoses including senile degeneration of the brain, dementia, and major depressive disorder with severe psychotic symptoms. The resident was under hospice care and had an identified RP. The decision to discontinue the medication was made by the interdisciplinary team (IDT) following a recommendation from the physician's assistant, and the team agreed to the discontinuation. Upon review of the resident's medical record, there was no documentation that the RP or hospice provider had been informed of the medication change. The facility's policy requires the IDT, in conjunction with the resident and their family or legal representative, to develop and implement a comprehensive, person-centered care plan, including participation in care planning and notification of significant changes. The lack of documentation and notification meant that the RP and hospice provider were not included in the decision-making process regarding the resident's care.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure regarding access to personal and medical records for one resident. Specifically, a resident submitted an Authorization to Release Medical Records (ARMR) form, which was signed and dated, requesting access to their medical records. The Medical Records Director confirmed that the request was not for legal reasons and was made directly by the resident. Despite the facility's policy stating that residents may obtain copies of their records within two business days of an oral or written request, the records were not provided to the resident until 15 days after the request was submitted, as evidenced by a certified mail receipt. This delay resulted in a violation of the resident's rights to timely access their personal and medical records.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by delayed responses to call lights and unmet basic care needs for one resident. The resident, who was cognitively intact and required substantial to maximal assistance for toileting and was dependent for toilet transfers, reported waiting 40 minutes for assistance after activating the call light due to a full urinal. Unable to wait any longer, the resident urinated on himself and his bedding, resulting in emotional distress and feelings of worthlessness. The resident stated that call light wait times on evening and night shifts ranged from 20 minutes to two hours, and that staff did not respond promptly to requests for help. Interviews with CNAs confirmed that staffing levels were insufficient, with one CNA assigned to as many as 24 residents on some shifts and reporting that call lights were often answered late due to workload. Another CNA reported being assigned 12 to 20 residents and described short staffing as a common occurrence, making it difficult to meet residents' needs and requiring staff to skip breaks. The facility's policy requires sufficient nursing staff to provide care in accordance with resident care plans, but observations and staff interviews indicated that this standard was not met.
Failure to Update Resident Care Plan After Discontinuation of Fluid Restriction Order
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with a history of fluid overload. A Certified Nursing Assistant (CNA) identified that the resident had a green sticker on the door, indicating a fluid restriction was in place. Review of the resident's care plan showed an intervention for fluid restriction of 1500ml per day, which had not been updated. However, upon review of the resident's active orders with the Director of Nursing (DON), it was found that the fluid restriction order had been discontinued several months prior, but the care plan was not updated to reflect this change. The facility's policy requires that clinical records accurately reflect the care provided to ensure continuity of care, which was not followed in this instance.
Failure to Administer Medications per Physician Orders for Bowel Management
Penalty
Summary
The facility failed to administer medications according to physician orders for one resident who experienced multiple episodes of loose stools. The resident was prescribed Docusate Sodium for constipation with specific instructions to hold the medication if loose stools occurred. Despite this, the medication was not held on several occasions when the resident had documented episodes of loose stools, as confirmed by both the Activities of Daily Living flowsheet and the Medication Administration Record. The Director of Nursing acknowledged that the medication should have been withheld during these episodes, in accordance with the physician's orders. Additionally, the resident had physician orders for Imodium and Loperamide to be administered as needed for diarrhea. However, during at least two documented episodes of loose stools, neither medication was administered as ordered. The facility's policy and procedure required medications to be administered in accordance with prescriber orders, but this was not followed in the resident's case. The failures were confirmed through interviews and record reviews with the Director of Nursing.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician's orders for one resident. The resident was prescribed Apixaban for atrial fibrillation and Metoprolol for hypertension, both to be administered twice daily at 9 a.m. and another time. On the specified date, the resident did not receive these medications at the scheduled 9 a.m. time. Instead, the medications were administered at approximately 12 p.m., outside the facility's policy of administering medications within one hour of the prescribed time. The delay occurred because the medications were not found in the medication cart and had to be retrieved from the cubex machine. The resident, who was cognitively intact with a BIMS score of 15, reported the delay and noted that his blood pressure was elevated at the scheduled medication time, which was confirmed by the nurse on duty. The nurse acknowledged that the medications were not administered as ordered and that the facility's policy and procedure for timely medication administration was not followed. The Director of Nursing also confirmed that the medications were not given within the required timeframe and that the policy was not adhered to.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident in a timely manner to the California Department of Public Health and the local ombudsman. The incident involved a resident who reported that a Licensed Vocational Nurse (LVN) entered her room and kissed her on the corner of her mouth, making her feel uncomfortable and unsafe. The resident, who was cognitively intact with a BIMs score of 15, reported the incident to another LVN on the same day it occurred. However, the Director of Nursing (DON) did not report the incident to the appropriate authorities until several days later, which was not in compliance with the facility's policy requiring immediate reporting. The delay in reporting the incident resulted in the resident experiencing increased anxiety, for which she was prescribed hydroxyzine. The facility's policy and procedure on abuse reporting clearly stated that any suspicion of abuse must be reported immediately to the administrator and relevant authorities, with specific time frames outlined for different types of abuse. Despite this, the report of suspected abuse was not submitted within the required time frame, potentially leaving the resident unprotected from further abuse and causing emotional distress.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. Resident 1, who had severely impaired cognition with a BIMS score of 3, required substantial assistance with transfers. On one occasion, a Certified Nursing Assistant (CNA) witnessed Resident 2, who was cognitively intact with a BIMS score of 15, physically assaulting Resident 1 by hitting them in the chest. This incident was reported to Licensed Vocational Nurses (LVNs) but no immediate protective measures were taken. Prior to the physical assault, another CNA had observed Resident 2 verbally abusing Resident 1 by yelling and using profane language. This verbal abuse was reported to an LVN, who failed to intervene or separate the residents, potentially preventing the subsequent physical abuse. The facility's policy on abuse prevention, which mandates the protection of residents from abuse by others, was not adhered to, as evidenced by the lack of action taken to protect Resident 1 from further harm.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not submit the SOC 341, a report of suspected dependent adult/elder abuse, to the California Department of Public Health (CDPH) and the local ombudsman within the required timeframe for two residents involved in a resident-to-resident physical abuse incident. The Director of Nursing (DON) confirmed that the incident occurred on January 31, 2025, but was unable to provide evidence that the report was submitted within 24 hours as required by the facility's policy and state law. Additionally, the facility did not conduct a thorough investigation of the resident-to-resident physical abuse incident. The DON, who was responsible for the investigation, confirmed that only the Certified Nursing Assistant (CNA) who witnessed the incident, the charge nurse on duty, and the two residents involved were interviewed. The facility's policy requires a more comprehensive investigation, including interviewing all staff members who had contact with the residents during the period of the alleged incident and reviewing all events leading up to the incident. This incomplete investigation could potentially result in an incomplete understanding of the incident.
Failure to Implement IDT Recommendations for Resident Monitoring
Penalty
Summary
The facility failed to consistently implement the Interdisciplinary Team (IDT) recommendations for two residents involved in a physical altercation. The IDT had recommended monitoring both residents for mood changes and delayed signs or symptoms of injury following the altercation. However, upon review, it was found that there was no documentation of such monitoring for either resident from February 1 to February 4, 2025. The facility's policy and procedure on comprehensive, person-centered care plans require the IDT to develop and implement care plans that include measurable objectives and timetables to meet residents' needs. The care plans should be reviewed and updated when there is a significant change in a resident's condition. Despite these requirements, the facility did not document the necessary monitoring for the residents involved in the altercation, potentially leaving their physical and psychosocial needs unmet.
Failure to Document Resident Assessments After Verbal Altercation
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Change in Condition or Status' by not completing assessments for three residents following a verbal altercation incident. The incident involved a resident who had verbal altercations with another female resident and allegedly threatened two male residents. Despite these events, there was no documentation of assessments for the affected residents, which was a requirement according to the facility's policy. During an interview and record review, the Director of Nursing (DON) acknowledged that the Licensed Vocational Nurse (LVN) responsible had not documented the initial assessments for the residents involved in the verbal altercations. The facility's policy, dated February 2021, clearly stated that nurses must record information related to changes in a resident's medical or mental condition. The lack of documentation for the involved residents after the incident on February 12, 2025, was a direct violation of this policy.
Insufficient Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient staffing, resulting in delayed response times to call lights for three residents. Resident 1 reported that call lights took 30 to 45 minutes to be answered, with the worst wait time being two hours, occurring two to three nights a week. Resident 1 required substantial assistance for toileting hygiene and was dependent on staff for transfers. Resident 2 experienced wait times of one and a half to two hours for call lights to be answered at night, feeling forgotten by the staff. Resident 2 also needed substantial assistance for toileting hygiene and was dependent on staff for transfers. Resident 3 reported waiting 25 to 30 minutes for call lights to be answered during the graveyard shift, which happened a couple of times a week, causing skin irritation due to prolonged exposure to urine. Certified Nursing Assistants (CNAs) reported feeling rushed and hurried during their shifts, often caring for up to 16 residents when the facility was not fully staffed. This situation occurred one to two times a week due to staff call-outs. The facility's policy on staffing indicated that sufficient numbers of nursing staff should be provided to meet residents' needs, but the observed staffing levels did not align with this policy. The deficiency in staffing led to increased wait times for residents' basic needs, such as toileting and pain management, to be met.
Failure to Administer and Document Treatments as Prescribed
Penalty
Summary
The facility failed to ensure that medications and treatments were administered according to physicians' orders for two residents, leading to potential risks of worsening skin conditions and infections. During an interview and record review with the Director of Nursing (DON), it was confirmed that medications and treatments should be administered and documented as per the physician's orders. However, the Treatment Administration Records (TAR) for two residents showed multiple instances where treatments were not documented as administered. For one resident, the TAR indicated that treatments for moisture-associated skin damage (MASD) to the coccyx and peri area were not documented as administered on several occasions. Specifically, there were no records of treatment being administered during evening and night shifts on multiple dates in January 2025. This lack of documentation suggests that the treatments may not have been provided as required, potentially compromising the resident's skin integrity and increasing the risk of infection. Similarly, another resident's TAR showed that Nystatin Powder, prescribed for a fungal infection, was not documented as administered on numerous dates in January 2025. The facility's policy and procedure for administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with proper documentation. The DON confirmed the missing documentation, indicating a failure to adhere to professional standards of quality care.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its policy and procedures for the prevention of pressure injuries, resulting in a deficiency related to the care of a resident, identified as Resident 79. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, diabetes, and end-stage renal disease, was at risk for developing pressure ulcers. Despite this risk, the facility did not consistently evaluate, report, or document changes in the resident's skin condition. The resident's treatment records indicated that the last treatment for blisters on the feet was conducted over a month prior to the survey, and there were no current orders for dressing changes. Observations and interviews revealed that the resident's feet had not been assessed or treated since late October, and the dressings had not been changed in a timely manner. The resident experienced pain during dressing removal, and a possible unstageable deep tissue injury was identified on the right heel. The facility's documentation, including the Nursing Weekly Summary and Resident Shower Log, inaccurately reported no new skin issues, and there was a lack of documentation regarding physician notification or wound assessment. The facility's policies required regular skin assessments and documentation of any changes, but these were not followed. The Treatment Nurse and Director of Nursing acknowledged the lack of assessment and documentation, and the resident's medical records did not reflect any communication with the physician regarding the skin condition. This oversight led to the development of a facility-acquired pressure ulcer on the resident's right heel, causing pain and necessitating further medical evaluation and treatment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations and interviews. A treatment nurse was observed with long artificial nails while providing wound care, which is against CDC guidelines as germs can live under artificial nails even after handwashing or using hand sanitizer. The Infection Preventionist Nurse confirmed that staff providing direct care should not have long artificial nails. Additionally, a linen cart containing clean linens was covered with a frayed mesh material that did not fully protect the linens from environmental contamination. The Housekeeping Manager acknowledged that the cover should be intact to protect the linens from dirt and microorganisms. The facility's policy requires clean linen to remain hygienically clean through protective measures, which was not adhered to in this instance. Furthermore, two housekeeping carts were observed with trash bins that lacked lids, instead being covered with towels and caution signs. The Infection Preventionist Nurse stated that the bins should have lids, as per the facility's policy to maintain a clean and safe environment. Lastly, three resident rooms on Enhanced Barrier Precautions lacked necessary PPE supplies, despite facility policy requiring PPE availability outside resident rooms. The Infection Preventionist Nurse confirmed the absence of PPE in these rooms, which is crucial for infection control, especially for residents with multi-drug resistant organisms.
Failure to Document Advance Directive Assistance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding Advance Directives (AD) for three residents, identified as Resident 32, Resident 40, and Resident 28. During a review of the records, it was found that these residents had not executed an Advance Directive, and there was no documentation indicating that assistance to develop an AD was offered, accepted, or declined. The Director of Admissions confirmed that there was no process in place to document whether assistance was offered, and the current form used by the facility did not have a section to indicate if assistance was offered, accepted, or declined. The facility's policy, dated 2000, requires staff to offer assistance in establishing advance directives if a resident or their representative has not done so. The policy also mandates that nursing staff document the offer of assistance and the resident's decision to accept or decline it in the medical record. However, this procedure was not followed for the three residents in question, potentially leaving the facility unaware of their wishes for medical treatment.
Lack of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 19, had informed consent forms for psychotropic medications prescribed by a physician. Resident 19 was admitted with diagnoses of major depressive disorder and anxiety disorder. During an interview, Resident 19 expressed that she had not been included in the decision-making process regarding her prescribed medications for anxiety and depression. A review of her medical records revealed that she was prescribed Nortriptyline, Fluoxetine, and Alprazolam on various dates, but there were no informed consent forms documented for these medications. The facility's policy and procedure on Psychoactive/Psychotropic Medication Use required that informed consent be obtained and documented in the medical record prior to the administration of psychotropic medications. During a review of Resident 19's medical record with a Registered Nurse Consultant, it was confirmed that informed consents were missing for the prescribed medications. The Registered Nurse Consultant acknowledged that informed consents should have been completed when the medications were ordered, as per the facility's policy.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during meal assistance. During an observation and interview, a CNA was seen standing over a resident while assisting with meals, which the CNA acknowledged was inappropriate. The resident, who was bed-bound and required assistance with meals, was in an upright position in bed during this interaction. The facility's policy on meal assistance clearly states that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, specifically noting that staff should not stand over residents while assisting with meals. This failure to adhere to the policy had the potential to negatively impact the resident's emotions, behavior, and social needs.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could potentially impact their psychosocial and physical needs. During an observation, Resident 186 was found lying in bed with the call light clipped to the curtain, making it unreachable. A Certified Nursing Assistant acknowledged the issue, and the resident's care plan indicated a need for assistance with activities of daily living due to generalized weakness and abnormal gait. The care plan also encouraged the use of the call light for assistance. Similarly, Resident 13's call light was observed on the floor, out of reach, and the resident was unaware of its location. A Licensed Vocational Nurse confirmed that call lights should not be on the floor and should be within reach. Resident 13 required substantial assistance for toileting hygiene and had a cognitive impairment, as indicated by a Brief Interview for Mental Status score of 00. The care plan for Resident 13 also emphasized the importance of having the call light within reach.
Failure to Inventory Resident's Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the inventory and documentation of personal property for a resident, identified as Resident 50. Upon admission, Resident 50's belongings were not inventoried and documented, as evidenced by a blank Personal Belonging Inventory Checklist (PBIC) dated February 2022. This oversight was discovered during an interview with the Social Services Director (SSD) and a review of the facility's records, which showed no reported missing clothing items for 2024, despite Resident 50's claim of missing a grey jacket, blue sweater, and black sweater. The SSD confirmed that the facility's policy required personal property to be inventoried and documented upon admission and updated as necessary. However, Resident 50's PBIC remained blank, and no inventory sheet was found in the medical records department. The SSD acknowledged that if Resident 50 had belongings, the PBIC should not have been blank. Additionally, a progress note from February 2022 indicated that Resident 50 and a significant other had received their belongings and found a radio they were looking for, suggesting that an inventory should have been conducted at that time.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to complete a change of condition assessment and notify the physician regarding a significant weight loss experienced by a resident. The resident, identified as Resident 66, experienced a series of weight losses over several months, which were documented in the Weights and Vitals Summary. The resident's weight decreased from 139 pounds in May to 116.6 pounds by November, marking a 16% weight loss over six months. The Registered Dietitian confirmed that the weight loss percentages over various periods were significant, yet there was no documentation of a change of condition form or physician notification. During a review of the facility's policy on changes in a resident's condition, it was noted that the policy requires prompt notification of the resident's physician in the event of significant changes in the resident's condition. However, the Registered Nurse Consultant confirmed that there was no documentation in the medical record indicating that the physician had been notified of the resident's significant weight loss. This oversight resulted in the physician being unaware of the resident's ongoing weight loss, which was a deviation from the facility's established procedures.
Lack of Individualized Activities Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 10 and Resident 12, had individualized care plans for their preferred activities and interests. This deficiency was identified during a review of the residents' admission records and medical records. Resident 10 was admitted to the facility on an unspecified date, and during a review with the Director of Activities (DOA), it was confirmed that Resident 10 did not have an individualized activities care plan. Similarly, Resident 12, who was also admitted on an unspecified date, was found to lack an individualized activities care plan during a concurrent review with the DOA. The facility's policy and procedure, titled 'Activity Evaluation' and dated February 2023, mandates the development of an individual activities care plan to allow residents to participate in activities of their choice and interest. The absence of these care plans for Resident 10 and Resident 12 had the potential to result in unmet psychosocial needs.
Failure to Assist Resident in Obtaining Hearing Aids
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Sensory Impairments- Clinical Protocol' for a resident who required assistance in obtaining hearing aids. The resident, along with their spouse, reported that the facility had checked the resident's hearing a long time ago, and the spouse confirmed the need for hearing aids. A review of the resident's Pure Tone Audiogram from March indicated significant hearing loss qualifying for hearing aids under their Medicare Plan. However, the resident's care plan from May 2022 and October 2024 noted the resident's hard of hearing condition and risk for impaired communication, yet no action was taken to provide the necessary hearing aids. The Social Services Director acknowledged that the resident had been seen by the facility's audiology company, but the company did not work with the resident's managed Medicare Plan for hearing aids. This issue should have been addressed sooner, as the need for hearing aids was determined in March. The resident expressed difficulty in communication, requiring others to repeat themselves and having to keep the TV volume high, which disturbed their spouse. The facility's policy required staff to help residents obtain hearing evaluations and hearing aids, which was not followed in this case.
Failure to Provide Timely Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide timely podiatry services for Resident 79, who had overgrown and thickened toenails. Resident 79 was admitted with multiple diagnoses, including type 2 diabetes mellitus, which necessitates specialized foot care. Despite having an active order for a podiatry consult and treatment since admission, the resident's toenails were observed to be long, thick, and yellowing, with dry, scaly skin. Treatment Nurse 1 and Certified Nursing Assistant 1 both noted the condition of the resident's feet, emphasizing the need for professional podiatric care due to the resident's diabetic status. The facility's policy on podiatry services requires that residents with complicating disease processes, such as diabetes, be referred to qualified professionals like a podiatrist. However, the policy was not followed in a timely manner for Resident 79, as the podiatry consult had not been conducted by the time of the survey. The Director of Nursing confirmed that diabetic patients are referred to a podiatrist and acknowledged that Resident 79 was scheduled to see the podiatrist the day after the survey. The facility's failure to adhere to its policy potentially exposed Resident 79 to podiatric complications.
Failure to Assist Resident in Changing Power of Attorney
Penalty
Summary
The facility failed to provide necessary social services assistance to a resident who wished to change her Power of Attorney (POA). The resident expressed frustration and emotional distress due to her brother having control over her finances as her POA, which she regretted. Despite her requests for assistance in changing her POA, the facility did not take appropriate action to address her concerns. During an interdisciplinary team conference, the resident clearly stated her desire to remove her brother as her POA, but the Social Services Assistant (SSA) and Social Services Director (SSD) did not follow through with the necessary steps to assist her. Interviews and record reviews revealed that the resident had repeatedly expressed her dissatisfaction with her brother's control over her finances and her inability to access her financial information. Despite these concerns being documented in conference summaries, there was no evidence of investigation or documentation in social services progress notes. The Director of Nursing expected the SSD to address the resident's concerns immediately, but the SSD admitted to not taking any action. Additionally, the facility lacked a policy and procedure for the social services process related to POA changes.
Failure to Account for Controlled Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding controlled medications, specifically in the case of a missing Hydrocodone tablet for one resident. During an observation and interview with the Director of Nursing (DON), it was revealed that the controlled medications were not properly accounted for before disposal. The DON stated that nurses are supposed to return controlled medications to her when residents are discharged, medications expire, or orders change. However, the Controlled Medication Chain of Custody/Destruction log (CMDL) did not show a signature of receipt by the DON, which is necessary for proper reconciliation of controlled medications. Further investigation confirmed that one tablet of Hydrocodone was missing from a resident's bubble pack. The facility's policy, dated 2019, requires that discrepancies in controlled medication counts be reported to the Consultant Pharmacist, Medical Director, Administrator, and DON, who must then review and determine the cause of the discrepancy. The policy also mandates that controlled medications be securely stored and counted until they can be provided to the DON for destruction. The failure to follow these procedures resulted in the potential for drug diversion.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication storage, specifically for one resident, Resident 284. During an observation and interview with the Director of Nursing (DON), it was found that two 50 ml bottles of expired Daptomycin Intravenous Solution were stored in the refrigerator of the IV medication storage room. The DON acknowledged that the expired medication should not have been stored there and should have been placed in the medication dispensing bin. Furthermore, the DON admitted that there was no process in place for the surveillance of outdated medications in the storage rooms. The facility's policy and procedure, dated 2019, stated that outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to procedures. Additionally, medication storage conditions were to be monitored monthly, with corrective actions taken if problems were identified. However, the facility failed to implement these procedures, leading to the potential risk of expired medication being administered to Resident 284.
Delayed Dental Services for Resident with Weight Loss
Penalty
Summary
The facility failed to provide timely dental services for Resident 66, who experienced significant weight loss due to ill-fitting dentures. A dental referral was made on July 3, 2024, following a social services note for denture evaluation and treatment. However, the resident was not seen by a dentist until October 22, 2024, three and a half months after the referral. This delay in dental care had the potential to exacerbate the resident's difficulty in eating and contribute to further weight loss. Resident 66's weight records showed a decrease from 139 pounds on May 6, 2024, to 129.6 pounds by July 2, 2024, indicating a significant weight loss of 5% between June 5 and July 2, 2024. Despite this, there was no progress note or assessment by the Registered Dietitian (RD) for the July weight loss. The Director of Nursing (DON) and Social Services Director (SSD) both acknowledged that the expectation was for the resident to be evaluated as soon as possible when weight loss concerns were identified. The facility's policy on dental services, dated December 2016, stated that routine and emergency dental services should be available to meet residents' oral health needs in accordance with their assessment and plan of care.
Unauthorized Administration of Topical Medication by Unlicensed Staff
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications, specifically for a resident who received topical medication without a physician's order by unlicensed staff. The resident reported that Certified Nursing Assistants (CNAs) applied ointments under his belly to help heal wounds, despite there being no documentation or physician's order for such treatment in the resident's medical record. The Minimum Data Set Nurse confirmed the absence of documentation and stated that CNAs are not permitted to apply ointments, which are kept locked in the medication cart. Further interviews revealed that CNAs had been applying a barrier cream to the resident's abdominal folds, sometimes at the resident's request, without proper authorization or documentation. The Treatment Nurse confirmed that there were no treatment orders for the application of Thera Calazinc Body Shield, a skin protection ointment, and reiterated that CNAs are not allowed to administer medications. The Director of Nursing also stated that Calazinc is considered a medication and should not be applied by CNAs. The facility's policy on administering medications clearly states that only licensed individuals may administer medications, and all treatments must be recorded on the resident's treatment record.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medication, resulting in an incomplete and inaccurate medication administration record (MAR) for one resident. During an observation, the resident was found with a peripherally inserted central catheter (PICC) and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). A review of the MAR revealed that the administration of Cefepime, an antibiotic prescribed for the resident's wound infection, was not documented on four specific dates. The Director of Nursing confirmed the lack of documentation for these dates, which was contrary to the facility's policy requiring the individual administering the medication to initial the MAR after each administration.
Failure to Follow Physician's Orders for Cellulitis Treatment
Penalty
Summary
The facility failed to adhere to the physician's orders for a resident's treatment of cellulitis in the right lower extremities. The resident reported that no treatment was provided for five days in September. A review of the Treatment Administration Record (TAR) for September revealed missing documentation of treatments on specific dates, including 9/11, 9/12, 9/14, and 9/15. The prescribed treatment involved cleansing the affected area, applying medication creams, and wrapping with gauze. Additionally, another treatment involving Methol-Zinc Oxide External Ointment was also not documented on 9/11, 9/14, and 9/15. During an interview, the Director of Nursing confirmed that the treatments were not administered on those days. The facility's policy on medication orders, dated November 2014, outlines the procedure for recording treatment orders, specifying the treatment, frequency, and duration.
Pest Control Deficiency in Staff Break Room
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of cockroaches in the staff break room. Observations on September 3, 2024, revealed multiple cockroaches in various locations within the break room, including on the wall, countertop, and inside the cabinet under the sink. Interviews with staff members, including a Licensed Vocational Nurse, Certified Nurse Assistant, Housekeeper, Activity Assistant, and the Director of Nursing, confirmed the presence of cockroaches in the break room, with sightings reported as recently as the day before the observation. A review of the facility's Pest Control Service Slip/Invoices from June, July, and August 2024 indicated that pest control services were conducted in common areas, but there was no documentation of inspections specifically targeting the break room for cockroaches. The Director of Maintenance stated that he was unaware of the pest problem due to a lack of reports. The facility's policy on pest control, which was undated, stated that the facility should maintain an effective pest control program, but this was not effectively implemented in the break room.
Delayed Response to Call Lights for Two Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for two residents, Resident 2 and Resident 4, as observed and reported during a survey. Resident 2, who requires assistance with transfers and toileting, reported that his call light was answered up to an hour late. His Minimum Data Set (MDS) assessment indicated he is cognitively intact with a BIMS score of 15. Similarly, Resident 4, who also has a BIMS score of 15 and requires extensive assistance with transfers, reported waiting up to an hour for her call light to be answered. The facility's Resident Council Department Response documents from July and August 2024 highlighted ongoing issues with delayed call light responses, particularly during the night shift. The facility's policy, dated October 2010, mandates that call lights should be answered as soon as possible, which was not adhered to in these instances. This deficiency in timely response to call lights potentially impacted the residents' ability to receive necessary assistance with their activities of daily living.
Failure to Investigate Alleged Abuse Incident Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program for a resident when an alleged abuse incident was not investigated within the required five working days. During an observation and interview, a resident was found with a dime-sized purple discoloration on the left upper arm, which the resident attributed to being grabbed by a caregiver. Another caregiver confirmed that the resident reported being grabbed on the arm. The Director of Nursing, acting as the abuse coordinator, acknowledged the absence of documentation for the abuse investigation within the stipulated timeframe. A review of the facility's policy indicated that all possible incidents of abuse should be identified, investigated, and reported within the timeframes required by federal requirements. However, nine working days after the incident, there was still no documentation of the investigation summary, indicating a failure to comply with the policy.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that the call lights of four sampled residents were answered in a timely manner, potentially affecting their ability to receive assistance with activities of daily living (ADL) and impacting their quality of life. Resident 1 reported waiting up to an hour for assistance after using the call light, which was problematic given their need for help with transfers and toileting as indicated in their Minimum Data Set (MDS) and Care Plan. Resident 2 also experienced delays, waiting between 15 minutes to an hour for assistance with changing briefs, despite requiring staff assistance for toileting as per their MDS. Resident 3 reported waiting between 25 minutes to two hours for assistance, while Resident 4 experienced delays of 30 minutes to an hour. Both residents required assistance with toileting, as documented in their MDS. A Certified Nursing Assistant (CNA) acknowledged that staffing shortages sometimes contributed to these delays. The facility's policy, dated October 2012, stated that call lights should be answered as soon as possible, highlighting a discrepancy between policy and practice.
Failure to Provide Necessary Bathing Assistance
Penalty
Summary
The facility failed to ensure that three residents received the necessary care and assistance needed for showers and baths, resulting in inadequate cleanliness and potential infection risks. Certified Nursing Assistants (CNAs) reported frequent short staffing, which led to residents not receiving showers as scheduled. Resident 3, who was cognitively intact and dependent on assistance for bathing, reported that her shower schedule was frequently changed without her consent. Resident 7, also cognitively intact and requiring substantial assistance, developed a fungal infection after not being offered a shower or sponge bath for nine to eleven days. Resident 8, who was dependent on assistance for bathing, reported that CNAs often asked to give bed baths instead of showers due to being busy, resulting in several days without a shower. Documentation reviews confirmed these deficiencies. Resident 3 received only one bed bath per week for three weeks in April, while Resident 7 had no documented evidence of a shower or bed bath for the first two weeks of admission. Resident 8 received three bed baths in April and only one in May. The facility's policy and procedure for bathing, which aims to promote cleanliness and observe skin condition, was not followed, as evidenced by the lack of proper documentation and the residents' reports of inadequate care.
Insufficient Staffing Leading to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staffing for eight of nine sampled residents, resulting in significant delays in answering call lights. Residents reported waiting times ranging from twenty-five minutes to up to two hours for assistance with essential needs such as brief changes, fluids, snacks, and toileting. Multiple residents, including those with high cognitive function as indicated by their BIMS scores, expressed frustration and distress over the prolonged waiting times. They noted that staff often walked by call lights without responding, and some residents had stopped using the call light system altogether due to the lack of timely response. Interviews with Certified Nursing Assistants (CNAs) corroborated the residents' complaints. CNAs reported being assigned to care for an excessive number of residents, often ranging from 13 to 20 per shift, which hindered their ability to respond promptly to call lights. The CNAs acknowledged that short staffing was a frequent issue, occurring multiple times a week, and admitted to witnessing staff ignoring call lights. This inadequate staffing led to delays in providing necessary care, such as moving scheduled showers to later times without consulting the residents. The facility's policy and procedure on staffing and resident rights were reviewed and found to be in violation. The policy stated that the facility should provide sufficient and competent nursing staff to ensure resident safety and well-being, which was not adhered to. Residents felt neglected and disrespected, with some expressing feelings of worthlessness and anger due to the lack of timely assistance. The failure to meet these staffing requirements had the potential to cause physical and psychosocial harm to the residents.
Failure to Offer Bed Hold Notice
Penalty
Summary
The facility failed to ensure a bed hold was offered to Resident 8 during a transfer to the hospital. Resident 8, who had a BIMS score indicating cognitive intactness, was sent to the hospital for evaluation and treatment of abnormal laboratory results. Upon returning to the facility, Resident 8 found that all personal items and medically necessary equipment had been moved from the room, and another resident had been placed in the bed. Resident 8 stated that no bed hold notice was offered at the time of transfer. The Director of Nursing (DON) confirmed that Resident 10 was placed in Resident 8's bed during the absence and was unable to provide evidence that Resident 8 was given a bed hold notice. The facility's policy requires that residents or their representatives be provided written information about bed hold policies at least twice: well in advance of any transfer and at the time of transfer. The DON's review of Resident 8's medical record showed no documentation of such notice being given, indicating a failure to comply with the facility's policy and procedure on bed holds and returns.
Failure to Ensure Staff Competency in BIPAP Application
Penalty
Summary
The facility failed to ensure that three Licensed Vocational Nurses (LVN 1, LVN 2, and LVN 3) were competent in the application and operation of a Bi-Level Positive Airway Pressure (BIPAP) machine. This deficiency was identified during an interview with Resident 8, who reported that some nurses were not trained on the BIPAP machine, leading to an incident where the machine was placed on its side, causing water to enter the hose and resulting in the resident choking and coughing. A review of Resident 8's Minimum Data Set (MDS) indicated that the resident had a BIMS score of 15, showing cognitive intactness, and had an active order for BIPAP assistance due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The Director of Nursing (DON) confirmed that the three LVNs did not have the necessary competencies for the BIPAP application and operation, despite documenting its application in the Medication Administration Record (MAR) for Resident 8. The facility's policy and procedure on staffing, revised in August 2022, stated that the facility should provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to care for residents. However, the DON's review of the competencies of LVN 1, LVN 2, and LVN 3 revealed that they lacked the required skills for the BIPAP machine. This failure to ensure staff competency directly led to the incorrect application of the BIPAP machine on Resident 8, compromising the resident's well-being and safety.
Failure to Conduct Required Employee Screenings Before Hire
Penalty
Summary
The facility failed to ensure that four out of five sampled employees had the required screening prior to their date of hire, which had the potential to expose residents to abuse. During an interview and record review, it was found that CNA 2, CNA 3, LVN 1, and LVN 2 did not have their criminal background checks or reference checks completed before their hire dates. Specifically, CNA 2 and CNA 3 were hired without criminal background checks, and LVN 1 and LVN 2 were hired without reference checks. The facility's policy and procedure, revised in 2021, indicated that employee background checks should be conducted prior to the date of hire, which was not adhered to in these cases. Additionally, a facility document from 2013 required a minimum of two reference checks for each new hire, which was also not followed.
Failure to Implement Hand Hygiene Policy
Penalty
Summary
The facility failed to implement its hand hygiene policy and procedure, which is crucial for reducing the risk of transmitting infections among residents and healthcare personnel. During an observation, a Certified Nursing Assistant (CNA) was seen exiting a resident's room, doffing her personal protective equipment (PPE), and then crossing the hallway to another room without performing hand hygiene. The CNA admitted to not performing hand hygiene after assisting a resident who was positive for COVID-19. Similarly, a Therapy Assistant (TA) was observed entering and exiting a resident's room multiple times without performing hand hygiene. Additionally, a Housekeeper (HSK) was seen removing soiled gloves and putting on new ones without sanitizing her hands in between. These actions were observed in a facility where multiple residents and staff members were currently positive for COVID-19. The Infection Control Nurse (ICN) confirmed that the facility's policy requires staff to perform hand hygiene before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, and after removing gloves. The ICN also stated that the facility had identified four residents and twelve staff members positive with COVID-19. A review of the facility's hand hygiene policy, dated August 2019, indicated that hand hygiene is considered the primary means to prevent the spread of infections. The policy specifies the use of an alcohol-based hand rub containing at least 62% alcohol or soap and water in various situations, including before and after direct contact with residents and after removing gloves. The failure to adhere to these guidelines was observed in multiple instances, leading to a potential risk of spreading infections within the facility.
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.
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