Chapman Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 12232 Chapman Ave, Garden Grove, California 92840
- CMS Provider Number
- 055816
- Inspections on file
- 21
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Chapman Care Center during CMS and state inspections, most recent first.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with a gastrostomy tube and physician orders for Enhanced Barrier Precautions (EBP) did not have a care plan developed to address EBP status. Medical record review and staff interviews confirmed the absence of a care plan for EBP, despite facility policy and physician orders requiring one. The DON and Administrator acknowledged the deficiency.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses. Wet blenders were improperly stored, a cutting board was unsanitary, and the ice machine was not thoroughly cleaned. Additionally, food brought by families was improperly labeled and stored, contrary to facility policy. These issues were confirmed by the DSS and LVN.
A resident was found self-administering lidocaine 5% cream without a physician's order or proper assessment deeming them safe for self-administration. The facility's policy requires an IDT assessment for self-administration, which was not followed, as the resident's assessment indicated they were not a candidate for safe self-administration.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their well-being and care. One resident in a wheelchair could not reach the call light clipped on the headboard, while another in bed found the call light too short to reach. Both CNAs confirmed these observations, and the DSD stated that call lights should always be accessible.
A facility failed to refer a resident for a PASRR Level II review after a diagnosis change from Alzheimer's with psychosis to schizoaffective disorder. Despite a psychiatric evaluation and a physician's order for risperidone, there was no documented evidence of a referral for the necessary review. Interviews with the ADON and DON confirmed the oversight, acknowledging that the PASRR Level I Screening did not reflect the new diagnosis and that a review should have been conducted.
A resident experienced significant weight loss, and the facility failed to follow the RD's recommendations for nutritional interventions. Despite the resident's severe cognitive impairment and multiple comorbidities, the RD's suggestions for an appetite stimulant, snacks, and a high-calorie drink were not communicated to the physician or discussed in IDT meetings, leading to inadequate nutritional care.
The facility failed to update tube feeding care plans and ensure physician's orders included start and stop times for two residents. The care plans did not reflect the revised feeding orders, and the orders lacked critical details, posing a risk for complications. Interviews with the DON and an LVN confirmed these deficiencies.
The facility failed to provide adequate respiratory care for several residents, including improper oxygen administration, lack of required signage, and unsanitary storage of equipment. A resident's oxygen was administered by unlicensed personnel without proper documentation, and multiple residents lacked 'No Smoking/Oxygen in Use' signs. Additionally, a resident's ventilator settings were not monitored as frequently as ordered, and another resident's oxygen and suction equipment were not maintained per physician orders.
A facility failed to ensure accurate documentation of a resident's permacath site for dialysis, leading to potential delays in care. The resident's medical records incorrectly noted the permacath site on the left upper chest, while it was actually on the right. This discrepancy was confirmed by both an LVN and an RN during an observation and interview.
The facility failed to ensure two residents were free from hazards associated with elevated side rails. One resident did not have informed consent or a care plan for grab bars, while another did not have less restrictive alternatives considered before installation. Informed consent documentation was incomplete, lacking details on who obtained consent. These deficiencies posed risks of entrapment and injury.
The facility did not act on the Pharmacy Consultant's recommendations for two residents. A resident's tramadol label was not updated to reflect pain management, and another resident did not receive recommended A1C monitoring. The DON confirmed the lack of follow-up, attributing responsibility to RN 1.
A facility failed to monitor a resident for orthostatic hypotension while they were on psychotropic medications, including Wellbutrin, quetiapine, and trazodone. Despite the potential for adverse complications, there was no order or evidence of monitoring in the resident's medical record. An RN confirmed the lack of monitoring, highlighting a deficiency in the facility's care practices.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.41% error rate. A resident did not receive Metamucil 4 in 1 Fiber due to unavailability, and an incorrect dosage of enoxaparin sodium was administered. The errors were made by an LVN, and the DON confirmed the findings.
A resident received 100 mg of enoxaparin sodium instead of the prescribed 10 mg dose due to a medication administration error by an LVN. The error was confirmed by the LVN and the DON, and the resident was transferred to the ER for monitoring at the family's request. The facility's policies require medications to be administered as prescribed, which was not followed in this case.
The facility failed to ensure proper medication storage and labeling, with issues including an unlocked medication cart, improper storage of on-hold medications, and damaged medication packaging. Medications were also left at residents' bedsides, and a medication label did not match the physician's order. These deficiencies were verified by nursing staff.
A resident on a mechanical soft, finely chopped diet was served large pieces of meat and hard toast, contrary to their prescribed diet. Staff, including a CNA, RN, DSS, and ADON, were involved in the oversight, with the RN and DSS acknowledging the meal did not meet dietary requirements. The ADON confirmed the meal was not consistent with the resident's prescribed diet.
A facility failed to ensure proper storage and labeling of food items brought in by family or visitors for a resident, potentially leading to foodborne illnesses. Unlabeled and undated food items were found in a resident's room, and staff interviews revealed a lack of awareness and adherence to the facility's policy on outside food. The absence of a thermometer in the resident's refrigerator indicated a lack of temperature monitoring, and the Maintenance Supervisor was unaware of the refrigerator's presence, which was against facility policy.
The facility failed to ensure accurate medical records for two residents. A resident's H&P form was improperly corrected, and another resident's psychotropic medication consent forms were incomplete. Additionally, a medication route was incorrectly documented, indicating administration via a GT, which the resident did not have. These issues were confirmed by the DON and an RN.
A facility failed to provide necessary hospice care for a resident, as a hospice aide improperly administered oxygen without notifying a nurse, and the facility did not ensure physician-ordered hospice visits were conducted. There were missing clinical notes and discrepancies in visit frequencies, leading to potential delays in care and communication issues.
The facility failed to adhere to infection control practices, including transporting uncovered linen carts and neglecting hand hygiene during resident care. A laundry aide was observed pushing an uncovered linen cart, and staff did not perform hand hygiene between assisting residents or during wound care. These actions were acknowledged by the staff and management as breaches of protocol.
The facility failed to conduct regular bed inspections to identify potential entrapment risks for three residents. Despite guidelines requiring regular inspections, the facility did not perform necessary measurements for entrapment zones, leading to potential safety hazards. For one resident, the maintenance supervisor was unaware of entrapment assessment requirements, and another resident's bed rails were found to be loose and unstable. Additionally, a third resident used grab bars without an entrapment assessment being conducted.
A facility failed to implement a care plan intervention for a resident at high risk for falls. The care plan required a yellow ID band to indicate the resident's fall risk status, but during an observation, the resident was found without it. The resident had cognitive deficits, impaired safety awareness, and a seizure disorder, increasing their fall risk. LVN 11 confirmed the oversight and applied the ID band, and the DON verified the care plan requirement.
A facility failed to promote dignity and respect for a resident during meal assistance. A CNA was observed standing over a resident with moderate cognitive impairment while assisting with eating, contrary to the facility's policy requiring staff to be seated beside or at eye level with residents. The CNA acknowledged the action, and the DSD confirmed the policy, highlighting a lapse in adherence to procedures designed to support resident dignity.
A facility failed to ensure proper placement of a catheter bag for a resident with an indwelling urinary catheter, as the bag was observed above bladder level, contrary to facility policy. This oversight, confirmed by an LVN, risked urine backflow and potential infection. The resident had a care plan addressing infection risk due to obstructive uropathy.
A facility failed to monitor a resident's blood pressure before administering metoprolol, an antihypertensive medication, as prescribed. The resident's physician ordered the medication to be held if the systolic blood pressure was less than 110 mmHg. However, the medication was administered on three occasions without documented blood pressure checks, as confirmed by an RN. This oversight had the potential to negatively affect the resident's health.
An activity staff member failed to immediately report an incident where a family member hit a resident with severe cognitive impairment on the head. The facility's policy requires immediate reporting to the Charge Nurse, but the incident was reported to social services nearly 22 hours later, delaying the investigation and mandatory reporting.
A resident with hypertension did not receive the correct diet as ordered by the physician, which was a regular diet with no added salt. The meal included a salt packet, and the dietary card, diet order form, Kardex, and food cart log all incorrectly indicated a regular diet. The LVN responsible for verifying meal trays admitted to an oversight, and the DSS confirmed the incorrect transcription of dietary orders.
A resident fell and sustained a fracture when the shower chair wheels were not locked upon arrival at the shower room. The facility's P&P required locking brakes to prevent falls, but this intervention was not included in the resident's care plan. The incident occurred due to the CNA's failure to lock the shower chair brakes, resulting in the resident falling and sustaining a comminuted fracture of the tibial plateau.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Develop Care Plan for EBP Status with Gastrostomy Tube
Penalty
Summary
A deficiency occurred when the facility failed to develop a care plan problem for a resident who was placed on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube (GT). The facility's policy requires a comprehensive, resident-centered care plan with measurable objectives and timeframes for each resident, based on their comprehensive assessment. Medical record review showed that the resident was readmitted to the facility and had physician orders to check GT placement and patency every shift, as well as to implement EBP every shift due to the GT. However, review of the resident's care plan did not show any care plan developed to address the EBP status as ordered by the physician. During interviews, the RN confirmed that no care plan was developed for the resident's EBP related to the GT, despite the physician's order and the resident having the GT since readmission. The RN explained that the admitting nurse initiates the baseline care plan, and other RNs or MDS staff add care plans as needed. The DON also confirmed that the care plan should have been initiated after receiving the physician's order for EBP and that MDS staff are responsible for reviewing care plans for completion. Both the DON and Administrator acknowledged the findings.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, which could potentially lead to foodborne illnesses among residents. During an observation, four blenders were found stored wet, contrary to the USDA Food Code 2022, which requires equipment to be air-dried before storage to prevent microorganism growth. Additionally, a red cutting board was heavily marred and discolored, making it difficult to clean and sanitize, thus posing a risk of transferring pathogenic microorganisms to food. The ice machine was also found in an unsanitary condition, with dry dust and white residue present, despite being cleaned by an outside company. This was verified by the Maintenance Director and the Dietary Services Supervisor (DSS), who acknowledged the oversight in ensuring thorough cleaning. Furthermore, the facility did not follow its policy regarding the storage of food brought in by families. An inspection of the resident refrigerator revealed several items, including jellos, onion dip, cottage cheese, and cheddar cheese, that were improperly labeled or undated. The facility's policy states that such food items should not be stored or reheated and must be consumed or discarded immediately. The Licensed Vocational Nurse (LVN) and DSS confirmed these findings, acknowledging that the items should have been properly labeled and stored according to the facility's policy.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, specifically lidocaine 5% cream. The resident was observed with the cream at their bedside and stated they applied it themselves, with the nurses being aware of this practice. However, there was no physician's order for the lidocaine cream or for the resident to self-administer it. Furthermore, an assessment had determined that the resident was not a candidate for safe self-administration of medications. The facility's policy requires that residents be assessed by the Interdisciplinary Team (IDT) to determine if self-administration is clinically appropriate. Despite this policy, the resident's medical records did not include a physician's order for the lidocaine cream or for self-administration, and the resident's assessment indicated they were not suitable for self-administration. Interviews with facility staff confirmed these findings, highlighting a lapse in adherence to the facility's policies and procedures regarding medication self-administration.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for two residents, which could potentially impact their psychosocial well-being or delay their care. Resident 339 was observed sitting in a wheelchair near the foot of the bed, unable to reach the call light, which was clipped on the right side of the headboard. The resident expressed that the CNA had changed her bed and forgot to place the call light within her reach. Resident 339 was cognitively intact and dependent on assistance for toileting and lower body dressing. Similarly, Resident 45 was observed sitting in bed and unable to reach the call light, which was clipped on the left side rail. The resident attempted to use her right arm to reach the call light but found it too short. Both CNAs verified the observations, and the DSD confirmed that the call light should be within the resident's reach at all times when in bed, chair, wheelchair, or bathroom.
Failure to Conduct PASRR Level II Review for Resident with New Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a PASRR Level II review after a change in diagnosis from Alzheimer's with psychosis to schizoaffective disorder. This oversight was identified during a review of the resident's medical records, which showed that the resident was initially screened with no diagnosis of a serious mental disorder. However, a subsequent psychiatric evaluation revealed the new diagnosis, and a physician's order was made to administer risperidone for schizoaffective disorder. Despite this change, there was no documented evidence of a referral for a Level II review, which is necessary to determine the appropriate level of care and services for the resident's condition. Interviews with the ADON and DON confirmed the findings, acknowledging that the PASRR Level I Screening did not reflect the resident's new diagnosis. The ADON admitted that the diagnosis was added after the initial screening and that a review should have been conducted to update the PASRR level. The DON also verified that a PASRR resident review should have been performed to ensure the resident received the necessary specialized care. The facility's failure to conduct this review was acknowledged by both the Administrator and the DON during the survey process.
Failure to Follow RD Recommendations for Nutritional Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 26, received the necessary nutritional interventions to maintain acceptable parameters of nutritional status. Resident 26 experienced a significant weight loss of 11 pounds over 20 days, which was not adequately addressed by the facility. The Registered Dietitian (RD) made recommendations on September 26, 2024, for an appetite stimulant, snacks three times a day, and a very high-calorie nutritional drink twice a day. However, these recommendations were not followed up with the physician, nor were they discussed in the Interdisciplinary Team (IDT) weight variance meetings. Resident 26 was admitted to the facility with diagnoses including right heart failure, acute respiratory failure, and dysphagia, and had severe cognitive impairment requiring assistance with eating. Despite the RD's recommendations being crucial for maintaining the resident's nutritional status, there was no documentation in the medical record indicating that the physician was notified of these recommendations. The Assistant Director of Nursing (ADON) acknowledged the lack of follow-up and documentation regarding the RD's recommendations. The facility's policy required that residents with weight variances be reviewed by the IDT, and any significant weight changes should be addressed. However, the RD's recommendations were not discussed in the IDT weight variance meetings, as confirmed by the Director of Nursing (DON). The failure to follow up on the RD's recommendations and discuss them in the IDT meetings contributed to the deficiency in providing adequate nutritional care for Resident 26.
Deficiency in Tube Feeding Care and Documentation
Penalty
Summary
The facility failed to ensure that necessary care and services related to gastrostomy tube (GT) feeding were provided for two residents. Specifically, the facility did not update the tube feeding care plans for these residents following revisions to their tube feeding orders. For one resident, the care plan still indicated the use of a different feeding formula and rate than what was currently ordered by the physician. Similarly, the other resident's care plan did not reflect the updated feeding formula and rate as per the physician's latest order. This discrepancy between the care plans and the physician's orders posed a risk for complications related to GT feeding. Additionally, the facility did not ensure that the physician's orders for GT feeding included a start time and specified stop time or the instruction to continue until the dose was complete. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the orders lacked these critical details. The LVN stated that in the absence of specified start and stop times, they would typically begin the feeding at a standard time but acknowledged that the orders should include these details. The DON verified that all orders should have a start time and specify until the dose is complete, which was missing in the orders for the two residents.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for several residents, as observed during a survey. For Resident 70, oxygen administration was not performed by a licensed nurse, and the administration was not documented in the Medication Administration Record (MAR). Additionally, a 'No Smoking/Oxygen in Use' sign was not posted outside the resident's door, contrary to the facility's policy and procedure (P&P). The Hospice Aide administered oxygen without consulting a licensed nurse, and the resident's oxygen saturation levels were not adequately reported or documented. Multiple residents, including Residents 23, 37, 51, 76, and 339, did not have the required 'No Smoking/Oxygen in Use' signs posted outside their rooms, as per the facility's P&P. This oversight was verified by various staff members, including registered nurses and licensed vocational nurses, during the survey. The absence of these signs poses a potential risk to the safety and well-being of the residents, especially those dependent on oxygen therapy. Additional deficiencies were noted in the sanitary storage of respiratory equipment. Resident 340's suction equipment and Resident 338's nasal cannula tubing were not stored in a sanitary manner. Furthermore, Resident 588 was not administered oxygen as ordered by the physician, and the suction tubing and canister were not replaced as required. Resident 58's ventilator settings were not monitored as frequently as ordered by the physician, with documentation showing checks every six hours instead of the required four hours. These failures collectively indicate a lack of adherence to physician orders and facility policies, potentially compromising the respiratory health of the residents.
Inaccurate Documentation of Dialysis Site Location
Penalty
Summary
The facility failed to provide the necessary care and services for a resident requiring hemodialysis, specifically by not ensuring the physician's order and plan of care accurately reflected the location of the permacath site. The medical record review for the resident, who was admitted to the facility on an unspecified date, revealed a discrepancy between the documented location of the permacath site and its actual location. The initial nursing history and assessment indicated the permacath site was on the right upper chest, while the physician's order dated 11/26/24 incorrectly noted it on the left upper chest. This error was also reflected in the resident's plan of care dated 11/29/24. During an observation and interview on 12/5/24, the permacath site was confirmed to be on the right upper chest by both LVN 3 and RN 2, who verified the inconsistency in the medical records.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 29 and Resident 339, were free from accident hazards associated with the use of elevated side rails. For Resident 29, the facility did not obtain an informed consent or initiate a care plan for the use of bilateral grab bars, which were intended to facilitate bed independence. Despite the resident's capacity to understand and make decisions, the informed consent on file was from a previous admission, and no current consent or care plan was documented. For Resident 339, the facility did not implement the least restrictive alternatives before installing grab rails. Although the resident was cognitively intact and required substantial assistance for bed mobility, the informed consent forms did not indicate who obtained the consent or document any less restrictive alternatives prior to the installation of the grab bars. The ADON confirmed these findings and admitted to obtaining verbal consent without proper documentation of who obtained the signatures on the consent forms. These deficiencies were identified through observations, interviews, and medical record reviews, revealing a lack of adherence to the facility's policy on siderails or bedrails. The failures had the potential to place the residents at risk for entrapment and serious injury, as highlighted by the FDA's Safety Alert on entrapment hazards with hospital bed side rails.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for two residents. For Resident 6, the Pharmacy Consultant recommended changing the tramadol medication label to indicate it was for pain management rather than severe pain levels (7-10). However, this recommendation was not followed, and the label remained unchanged. There was no documentation explaining why the recommendation was not acted upon, and this was verified by RN 1 during an interview and medical record review. For Resident 29, the Pharmacy Consultant recommended A1C level monitoring every three months until the treatment goal was met, and then every six months. Despite a physician's signature on the recommendation form, there was no date or documentation of a response. Further review showed no A1C level results were completed after the recommendation date, and the DON confirmed there were no physician's orders or nurses' notes indicating follow-up on the recommendation. The DON stated that it was RN 1's responsibility to ensure follow-through on the drug regimen review.
Failure to Monitor for Orthostatic Hypotension in Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically by not monitoring for orthostatic hypotension, a potential side effect of the medications prescribed. The resident was prescribed Wellbutrin, quetiapine, and trazodone for depression and related symptoms, but there was no evidence in the medical record that the resident was monitored for orthostatic hypotension, which could lead to adverse complications. During an interview, a registered nurse confirmed that there was no order to monitor the resident for orthostatic hypotension, despite the use of psychotropic drugs. This oversight indicates a lapse in the facility's responsibility to monitor the resident's condition and ensure their safety while on these medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration observation. The cumulative medication error rate was 7.41% when two errors were observed in 27 opportunities. These errors were made by a licensed nurse (LVN 7) who administered medications to a nonsampled resident (Resident 688). The errors included failing to administer Metamucil 4 in 1 Fiber oral packet as ordered by the physician and administering an incorrect dosage of enoxaparin sodium. Resident 688, who was admitted to the facility with a history of DVT prophylaxis, was supposed to receive Metamucil 4 in 1 Fiber oral packet daily for bowel management. However, LVN 7 did not administer this medication because it was not available and pending pharmacy delivery. The Director of Nursing (DON) acknowledged that the medication was not a house supply and should have been ordered in advance by the charge nurse. Additionally, LVN 7 administered 100 mg of enoxaparin sodium instead of the prescribed 10 mg. This error was confirmed during an interview with LVN 7, who acknowledged administering the incorrect dosage. The DON verified the findings and stated awareness of the incident. The facility's policies and procedures for medication administration and ordering were reviewed, highlighting the need for accurate medication administration and timely ordering from the pharmacy.
Medication Administration Error for Anticoagulant
Penalty
Summary
The facility failed to ensure that Resident 688 was free from significant medication errors. During a medication administration observation, LVN 7 administered 100 mg of enoxaparin sodium instead of the 10 mg dose ordered by the physician for DVT prophylaxis. This error was confirmed by LVN 7, who acknowledged administering the incorrect dosage and stated she would inform her RN Supervisor and the DON. The facility's policies and procedures for medication administration require that medications be administered as prescribed and that the medication label be read before administration, which was not adhered to in this instance. Resident 688, who had intact cognition, was admitted to the facility with a history of DVT prophylaxis. The error was discovered during a review of the resident's medical records and confirmed through interviews with LVN 7 and the DON. The DON verified the incident and stated that the ADON was assessing Resident 688. The Pharmacy Consultant and Physician 1 were also informed of the error. Physician 1 noted that the error was a personal mistake by the nurse and suggested in-service training to prevent future occurrences. Resident 688 was transferred to the ER at the family's request for monitoring, although no immediate signs of bleeding were observed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications across several medication carts and resident rooms. Medication Cart A was left unlocked and unattended in front of the nursing station, allowing unauthorized access to medications. Medication Cart B contained IV medications that were on hold, stored alongside current IV solutions, contrary to the facility's policy that requires such medications to be stored separately. Medication Cart C had multiple issues, including the storage of medications on hold with current medications, mixing of orally administered medications with externally used medications, and damaged bubble packs containing medications. Specifically, Eliquis, an anticoagulant, was stored with other medications despite being on hold. Oral medications like Clearlax were stored with transdermal patches and nasal sprays, and bubble packs of levothyroxine and pantoprazole were found with tears or taped repairs. Additionally, medications were improperly left at residents' bedsides. A bottle of Zenpep was found on Resident 338's bedside table, and a cup of zinc oxide cream was left on Resident 339's bedside table. Furthermore, the label on the bubble pack of tramadol for Resident 6 did not match the physician's order, indicating it was for severe pain management rather than general pain management. These deficiencies were verified by the nursing staff and had the potential to impact the residents' well-being and medication safety.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a prescribed therapeutic diet to a resident, identified as Resident 5, who was on a mechanical soft, finely chopped diet. During a lunch observation, Resident 5 was served large pieces of meat and a half piece of hard toast, which were inconsistent with the ordered diet. The resident's medical records indicated a need for a fortified mechanical soft diet with finely chopped meat and vegetables, and the care plan emphasized the importance of monitoring for choking and swallowing problems. Multiple staff members, including a CNA, RN, DSS, and ADON, were involved in the oversight of Resident 5's meal. The CNA fed the resident, while the RN acknowledged the need for the toast to be chopped due to the resident's high risk for aspiration. The DSS admitted responsibility for ensuring the correct ingredients were served and confirmed the meat was not finely chopped. The ADON, who checked the tray before serving, also confirmed the meal did not meet the prescribed diet requirements, noting the toast was too hard and the meat was not finely chopped.
Improper Storage and Labeling of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items brought in by family or visitors for a resident, which could potentially lead to foodborne illnesses. During an inspection, it was observed that a resident had several food items, including an unlabeled and undated container of sliced apples, on their nightstand and inside a small refrigerator in their room. The facility's policy requires that food brought in from outside sources be checked by the dietary department or nursing staff to confirm it does not conflict with the resident's prescribed diet and that non-perishable foods be stored in plastic containers with tight-fitting lids or sealable bags and dated. However, these procedures were not followed, as evidenced by the presence of unlabeled and undated food items. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding food brought in from outside. A CNA was unaware of the policy, and an LVN stated that residents were allowed to have food from outside as long as there were no dietary restrictions, but fresh fruits should be stored for only one day. The DSD confirmed the findings and noted the absence of a thermometer in the resident's refrigerator, indicating a lack of temperature monitoring. Additionally, the Maintenance Supervisor was unaware of the refrigerator's presence in the resident's room, which was against facility policy, and stated that it should have been reported to the charge nurse or social services department.
Inaccurate Medical Records and Consent Form Deficiencies
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential unmet needs due to incomplete medical information. For Resident 64, an error on the History and Physical (H&P) evaluation form was not properly documented according to the facility's policy and procedure (P&P). The incorrect entry was scribbled out instead of being struck through with a line and initialed, as verified by the Director of Nursing (DON). This improper documentation practice was identified during a medical record review and interview with the DON. For Resident 29, there were multiple deficiencies in the medical records. The psychotropic medication consent forms were not properly completed by the physician, as sections regarding disclosure of risks and obtaining informed consent were left unchecked. Additionally, the Medication Administration Record (MAR) incorrectly indicated that trazodone was to be administered via a gastrostomy tube (GT), despite the resident not having a GT. These errors were confirmed during interviews with the DON and a registered nurse (RN), highlighting inaccuracies in the resident's clinical records.
Deficiency in Hospice Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for a resident who was under hospice care. The hospice aide improperly administered oxygen to the resident when their oxygen saturation level was at 78%, without notifying the licensed nurse. The facility's policy required that the hospice aide report such observations to the supervising nurse, but this was not done. Additionally, the hospice aide was not evaluated for competency in checking and monitoring the resident's oxygen saturation level, which contributed to the oversight. The facility also failed to ensure that the physician's orders regarding the frequency of hospice staff visits were followed. The medical records for the resident did not show evidence that the scheduled visits by skilled nurses, hospice aides, social workers, and spiritual counselors were carried out as ordered. There were discrepancies in the frequency of skilled nursing visits, and the facility did not clarify these orders. Furthermore, there were missing clinical notes for both skilled nursing and hospice aide visits on several dates, indicating a lack of proper documentation and communication between the hospice provider and the facility. The facility's policies and the agreement with the hospice provider outlined responsibilities for maintaining comprehensive assessments and ensuring timely hospice services. However, the facility did not adhere to these standards, resulting in potential delays in care and communication issues that could affect the resident's well-being. The Director of Nursing verified these findings during interviews and record reviews, confirming the deficiencies in care and documentation.
Infection Control Deficiencies in Linen Handling and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations. During the transportation of clean linen, a laundry aide was seen pushing an uncovered linen cart with her arm resting on the inner shelf, directly touching clean towels. This was contrary to the facility's policy, which mandates that linen carts should be covered during transport to prevent contamination. The maintenance supervisor confirmed that the linen cart should have been closed while being moved through the hallway. Additionally, staff failed to perform hand hygiene in critical situations. An RNA was observed assisting two residents with meals without changing gloves or performing hand hygiene between interactions, which was acknowledged by the RNA and the infection preventionist (IP) as a breach of protocol. Furthermore, during a wound treatment observation, an LVN did not perform hand hygiene before and after wearing gloves, despite the facility's policy requiring it. The LVN admitted to the oversight, and the IP confirmed the necessity of hand hygiene to prevent infection spread. The Director of Nursing (DON) and the Administrator were informed and acknowledged these findings.
Failure to Conduct Regular Bed Inspections for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular bed inspections as part of a maintenance program to identify potential entrapment risks for three residents. The FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment outlines seven zones where entrapment can occur, and the facility's policy requires regular inspections to prevent such risks. However, the facility did not adhere to these guidelines, leading to potential safety hazards for the residents. For Resident 339, the facility did not perform the necessary measurements for entrapment zones, despite the resident being at high risk for entrapment due to the use of bilateral grab bars. The maintenance supervisor was unaware of the entrapment assessment requirements and did not conduct individual bed inspections or measurements, relying instead on standard equipment dimensions. This oversight was confirmed during interviews with facility staff, who acknowledged the lack of proper documentation and assessment. Resident 51's bed rails were found to be loose and unstable, posing a risk of entrapment. The maintenance supervisor did not receive reports of the issue and did not perform individualized measurements for the resident's bed. Similarly, Resident 29 used grab bars without an entrapment assessment being conducted, as confirmed by the Director of Nursing and RN 1. These deficiencies highlight the facility's failure to ensure bed safety and compliance with established guidelines.
Failure to Implement Fall Risk Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as high risk for falls. The care plan, dated April 15, 2024, included an intervention to use a yellow-colored ID band to signify the resident's high fall risk status. However, during an observation on December 5, 2024, the resident was found without the yellow ID band, which was a required intervention according to the facility's fall risk prevention policy revised in July 2018. This oversight was confirmed during an interview with LVN 11, who acknowledged the absence of the ID band and subsequently applied it to the resident's wrist. The resident, admitted to the facility earlier in the year, had a history of cognitive deficits, impaired safety awareness, weakness, polypharmacy, impaired mobility, a high fall risk score, and a seizure disorder, all contributing to their high risk for falls. Despite these documented risks, the facility did not adhere to the care plan intervention of using a yellow ID band, which was intended to alert staff to the resident's fall risk status. The Director of Nursing also verified the care plan's requirement for the ID band during an interview, confirming the deficiency in implementing the resident's fall prevention measures.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that resident care was provided in a manner that promoted dignity and respect for a resident identified as Resident 70. During observations, a CNA was seen standing over Resident 70 while assisting with eating, rather than sitting beside the resident or at eye level, as required by the facility's policy. The CNA acknowledged standing over the resident and explained that sitting would make it too high to feed the resident. However, the facility's policy, as confirmed by the DSD, mandates that staff should be seated beside the resident or at eye level to promote dignity during meal assistance. Resident 70, who was admitted to the facility with a moderate cognitive impairment, required substantial to maximal assistance for eating, as indicated in the MDS. The failure to adhere to the facility's policy had the potential to negatively impact the resident's feelings of self-worth and well-being.
Improper Placement of Catheter Bag in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, specifically by not ensuring that the catheter bag was placed below the bladder level. This oversight was observed during a survey when the resident's catheter bag, filled with yellowish urine, was positioned higher than the bladder. According to the facility's policy and procedure for indwelling catheter use, the catheter and tubing must remain patent, with the drainage bag kept below the bladder level to maintain unobstructed urine flow and prevent backflow, which could lead to a urinary tract infection. The resident in question had a physician's order for an indwelling urinary catheter due to obstructive uropathy, with a care plan in place to address the risk of infection. The care plan included interventions to keep the catheter below the bladder level. During an interview, an LVN confirmed the improper placement of the catheter bag and acknowledged that placing the bag above the bladder could result in urine backflow, potentially causing a urinary tract infection. This failure to adhere to the care plan and facility policy posed a risk to the resident's health.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to adequately monitor the blood pressure of Resident 341 before administering metoprolol, an antihypertensive medication, as prescribed by the physician. Resident 341 had a physician's order to receive metoprolol 25 mg every Monday, Wednesday, and Friday in the evening, with instructions to hold the medication if the systolic blood pressure was less than 110 mmHg. However, a review of the Medication Administration Record (MAR) for November and December 2024 revealed that the medication was administered on three occasions without documented evidence of blood pressure monitoring prior to administration. An interview and concurrent medical record review with RN 2 on December 5, 2024, confirmed these findings. This oversight had the potential to negatively affect Resident 341's health condition and well-being, as the necessary precautionary measure of checking blood pressure was not followed.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when an activity staff member witnessed a family member hitting a resident on the head with her hand but did not immediately report the incident to the Charge Nurse. The facility's policy, revised in August 2018, mandates that staff notify the Charge Nurse as soon as possible, who would then inform the Administrator and Director of Nursing immediately. However, the activity staff member reported the incident to the social services staff nearly 22 hours later, which delayed the investigation and mandatory reporting. The incident involved a resident with severe cognitive impairment and dementia, who was unable to recall the event when interviewed. The resident was in the activity room when a family member aggressively intervened during a moment of confusion, resulting in the alleged abuse. Another resident corroborated the account, stating they witnessed the family member hitting the resident's head. The Administrator acknowledged the delay in reporting and confirmed that the staff should have reported the abuse allegation immediately.
Failure to Provide Correct Diet as Ordered
Penalty
Summary
The facility failed to provide a resident with the correct diet as ordered by the physician, which was a regular diet with no added salt. The resident, who had a diagnosis of hypertension, was observed eating a meal that included a salt packet, contrary to the physician's order. The dietary card, diet order form, Kardex, and food cart log all incorrectly indicated a regular diet without specifying the no added salt requirement. The Licensed Vocational Nurse (LVN) responsible for verifying the resident meal trays admitted to an oversight in ensuring the meal matched the physician's order. The LVN had returned the list of physician's orders to the kitchen and failed to verify the resident's lunch was consistent with the physician's order. Upon review, the LVN confirmed that the resident's lunch tray did not meet the prescribed dietary requirements. The Dietary Services Supervisor (DSS) was responsible for transcribing the dietary orders onto the Kardex and dietary cards. The DSS confirmed that the resident's diet order form, Kardex, food cart log, and dietary card all contained incorrect information, failing to reflect the no added salt requirement. The DSS stated there was no set interval for reviewing the physician's orders for resident diets, which contributed to the oversight.
Failure to Lock Shower Chair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to provide the necessary care and services to prevent a fall incident for a resident. The resident's shower chair wheels were not locked when arriving at the shower room. As the resident removed his cover and leaned forward, the shower chair moved and tilted forward, causing the resident to fall on his left knee and sustain a fracture. The facility's policies and procedures (P&P) for fall risk and prevention of injury, as well as the Falling Start Program, both include locking the brakes on beds, gurneys, or wheelchairs to prevent falls. However, the resident's care plan did not include this intervention, leading to the incident. The resident was readmitted to the facility with diagnoses of paraplegia and had a history of being at high risk for falls due to various factors including impaired mobility and balance problems. The resident's quarterly MDS assessment indicated that he was dependent on chair/bed-to-chair transfer and tub/shower transfers. The incident occurred when the CNA failed to lock the shower chair brakes, resulting in the resident falling and sustaining a comminuted fracture of the tibial plateau. Interviews with the resident, CNA, and ADON confirmed that the shower chair brakes were not locked at the time of the fall.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
