Corona Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corona, California.
- Location
- 2600 South Main Street, Corona, California 92882
- CMS Provider Number
- 555566
- Inspections on file
- 60
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Corona Post Acute Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain linens, shower curtains, and privacy curtains in a clean, stain-free condition as required by its infection prevention and control program. During observations with the Director of Housekeeping and Laundry, shower curtains in two shower rooms were noted with black and brown discoloration, and a stained linen item was found folded on a shelf in the clean linen closet, ready for resident use. In a resident’s room, the IP identified a brown streak on the privacy curtain and confirmed it was an infection control issue. The DON stated that linens and curtains designated as clean are expected to be free of stains to support a clean environment and prevent infection, in line with the facility’s infection control policy.
A resident with BPH, urinary incontinence, and urinary retention had an indwelling Foley catheter ordered and documented in the medical record, but the care plan incorrectly listed neurogenic bladder as a related diagnosis. Review of physician documentation and diagnoses showed no evidence of neurogenic bladder, and both the MDS Supervisor and DON confirmed that this diagnosis was inaccurate and should not have been included in the care plan, resulting in an inaccurate medical record.
A resident with chronic kidney disease was discharged, and a written request for their medical records was submitted by the legal representative. The facility failed to provide access to the records within the required 48-hour timeframe, instead delaying the release for 27 days after forwarding the request to the legal department, which did not comply with regulatory requirements.
A resident with a history of spinal fusion and depression was discharged without the required physician documentation providing clinical rationale for the discharge. Although the resident was noted to benefit from continued care, a discharge notice was issued and the medical record did not include evidence that the resident no longer required facility services or that discharge was appropriate, as required by facility policy.
Two LVNs did not wear required gowns while administering medications via G-tube to two residents on Enhanced Barrier Precautions for MDROs, despite care plans and orders specifying the use of PPE for high-contact activities involving feeding tubes and indwelling devices. Both nurses acknowledged the requirement during interviews, and the facility's infection prevention policy confirmed the need for gowns and gloves in these situations.
A resident with a history of metabolic encephalopathy and right-sided hemiplegia, who required supervision with eating, was served a hot beverage by a CNA who failed to check the temperature as required by facility policy. The resident spilled the hot liquid, resulting in second and third degree burns to her right breast and shoulder, necessitating medical intervention. Staff interviews and documentation confirmed that the CNA was unaware of the temperature-checking requirement, and facility policy mandated hot beverages be served at or below 155°F.
Three residents experienced failures in timely assessment, monitoring, and follow-up of skin injuries and changes. One resident with burns did not receive prompt treatment or a specialist follow-up as recommended. Another resident with dementia and on anticoagulant therapy developed significant bruising that was not properly assessed or reported to a physician. A third resident with diabetic ulcers had worsening wounds that were not identified as a change in condition or communicated to the physician. These lapses were confirmed by staff interviews and documentation review.
A resident with ALS was unable to reach staff after her call light fell, and her family member's repeated phone calls to the facility went unanswered and unreturned. Interviews revealed that after-hours calls were not consistently answered or forwarded to residents, and two other residents also reported not receiving intended calls. The administrator acknowledged that calls should be answered and properly forwarded at all times.
A resident with spinal stenosis did not receive prescribed Hydrocodone because the medication was not reordered in advance, as required by facility policy. Nursing staff confirmed that the medication ran out and there was no documentation of a timely reorder, resulting in the pain medication being unavailable when needed.
A facility failed to provide a resident's medical records within the required 48-hour timeframe, resulting in a 14-business-day delay. The resident's legal representative requested the records with valid authorization, but the Medical Record Director did not follow up promptly with the legal team, causing the delay. This failure potentially denied the resident representative timely access to review records and make critical decisions.
The facility failed to provide pressure ulcer treatment as ordered for three residents. A resident with a Stage 4 ulcer was found without a dressing, and staff failed to ensure it was reapplied. Another resident with a similar condition also lacked a dressing, with poor communication among staff. A third resident at risk for ulcers did not receive consistent treatment, as an LVN signed off on care that was not provided. The DON and Administrator acknowledged the need for adherence to treatment orders.
A resident with hemiplegia was provided a wheelchair in poor condition, with burn holes and a torn armrest, by the facility. Staff interviews revealed that the wheelchair was mistakenly taken from a storage area meant for repairs, and the facility failed to ensure it was in good condition before use. The Director of Maintenance and Administrator acknowledged the error, and the Director of Nursing emphasized the expectation for well-maintained equipment.
A facility failed to refer a resident with bipolar disorder for a Level II PASRR screening. The resident was admitted with a negative Level I screening, which inaccurately indicated no serious mental illness. Despite the resident's medical history showing a bipolar disorder diagnosis, the facility did not identify this as an SMI. Interviews revealed that the MDS Coordinator was unaware of the inaccuracy, and the Director of Nursing was not involved in the PASRR process, leading to the oversight.
A resident with hemiplegia and hemiparesis was observed with long, dirty fingernails due to the facility's failure to provide adequate nail care. Despite the resident's request and the availability of nail trimmers, staff did not trim the resident's nails, citing an inability to locate the trimmers. Interviews revealed a lack of communication and awareness among staff regarding the resident's need for nail care.
A resident with COPD did not receive prescribed DuoNeb treatments due to a transcription error in the electronic health record, leading to infrequent administration. The nebulizer was not easily accessible, and staff failed to verify and double-check the order, resulting in inadequate respiratory care.
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. Staff did not follow the facility's policy or CDC guidelines, leading to the application of wound treatment with potentially contaminated gloves. Interviews revealed a lack of adherence to hand hygiene protocols, highlighting a significant lapse in infection prevention and control practices.
A resident with sepsis and enterocolitis experienced low blood pressure, recorded at 65/49, but was not reassessed or monitored while awaiting hospital transfer. Interviews revealed that the nursing staff failed to recheck the blood pressure, contrary to facility policy requiring documentation of condition changes.
A resident with Clostridium Difficile (C. diff) was placed on contact precautions, but the facility failed to provide disposable equipment, such as a stethoscope and sphygmomanometer, for the resident in isolation. This deficiency was confirmed by staff, including a CNA, RN, IP, and DON, who acknowledged the need for such equipment to prevent infection spread. The facility's policies emphasize the importance of dedicated equipment for residents on transmission-based precautions, but these were not followed, increasing the risk of infection transmission.
A legally blind resident with multiple medical conditions did not receive necessary assistance with meals, as observed during an unannounced visit. Despite care plan instructions for feeding assistance, staff left the resident's lunch tray without providing help. Interviews with staff confirmed a lack of adherence to the facility's policy on meal assistance.
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as per their policy. The process involved sending requests to the corporate office for approval, which took one to two weeks due to short staffing. This delay was identified during an unannounced visit, with requests pending approval and not fulfilled within the required timeframe.
A resident with Alzheimer's Disease was found with their call light out of reach during an unannounced visit. An LVN admitted the oversight occurred after repositioning the resident. The DON confirmed that staff are expected to ensure call lights are always accessible, as per facility policy.
A resident was exposed to pesticide vapor when the Maintenance Supervisor sprayed pesticide in the room while the resident was present, without notifying nursing staff or moving the resident. The facility's protocol requires residents to be relocated before such treatments, which was not followed, compromising the resident's safety and comfort.
A resident with a stage 4 pressure ulcer was not repositioned every two hours as required by their care plan. Observations showed the resident remained in the same position for over three hours. A CNA admitted to not repositioning the resident due to being busy, which was against the facility's policy and care plan directives.
The facility failed to maintain a clean and sanitary environment in two resident rooms. Observations revealed a brown splatter, dirty gloves, and dried blood in one room, and trash, food crumbs, and dust behind headboards in another. A resident confirmed the blood was from their toe, and the housekeeper admitted to not cleaning behind the headboards. A Registered Nurse verified the unclean conditions, which contradicted the facility's policy for a homelike environment.
A resident with depression and schizoaffective disorder was discharged to a hospital without receiving a written notice of transfer. The DON confirmed that the required Notice of Proposed Transfer/Discharge form was incomplete and not acknowledged by the resident, contrary to facility policy.
A resident reported feeling uncomfortable when a CNA touched her shoulder and breast without consent. The CNA admitted to the action, and the DON confirmed it violated the resident's rights to respect and dignity, as per the facility's policy.
A resident with paraplegia and a newly developed Stage 4 pressure ulcer was discharged to an assisted living facility without proper re-evaluation and communication of their condition. The receiving facility, unaware of the pressure ulcer, admitted the resident, who then required acute hospitalization due to the worsening condition.
The facility failed to properly manage and account for a resident's personal belongings, leading to missing items such as groceries, dentures, contact lenses, underwear, and a speaker. The Inventory of Personal Effects form was not properly filled out or signed by staff upon both admission and discharge, resulting in a deficiency in honoring the resident's right to a dignified existence and self-determination.
A resident with diabetes and dementia experienced significant weight loss due to the facility's failure to provide RNA feeding assistance as ordered. Staff often provided only set-up or clean-up assistance, and the resident's family had to step in to help with meals. The facility's policy required physical prompts and verbal cues, but these were not consistently provided.
Soiled Linens and Curtains Not Maintained Clean Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program to ensure linens and environmental surfaces, including shower and privacy curtains, were maintained clean and free of visible soil. During an observation in the North shower room at 10:24 a.m., a shower curtain was noted with black stains and discoloration on the bottom; the Director of Housekeeping and Laundry (DHL) acknowledged it needed to be removed and washed. At 10:28 a.m., in the Medically Complex Unit shower room, another shower curtain was observed with brown stain discoloration, and the DHL again stated the curtain needed to be removed and washed. At 10:20 a.m., in the North clean linen closet, a linen item folded on the shelf and ready for resident use was observed with a visible stain mark, which the DHL stated should not be present and that the item needed to be discarded. At 10:52 a.m., in a resident’s room, the Infection Preventionist Nurse (IP) observed and acknowledged a brown streak stain on the resident’s privacy curtain, stating it should not have a stain, needed to be replaced, and that it was an infection control issue. Later, the Director of Nursing (DON) stated that clean linens in the clean linen closet, resident privacy curtains, and shower curtains should be clean and free from stain marks, and that the expectation is to maintain a clean and homelike environment and prevent the spread of infection, consistent with the facility’s Infection Prevention and Control Policy requiring a safe, sanitary environment with cleaning, disinfection, and linen handling procedures.
Inaccurate Diagnosis Documented in Catheter Care Plan
Penalty
Summary
The facility failed to ensure the accuracy of the medical record and care plan for one sampled resident when an incorrect diagnosis was documented. The resident was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, unspecified urinary incontinence, and urinary retention, and had an indwelling Foley catheter in place per physician orders and history and physical documentation. Review of the physician documentation and diagnoses showed no evidence that the resident had a diagnosis of neurogenic bladder. Despite the absence of this diagnosis in the medical record, the resident’s care plan documented that the resident had an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. During interview and concurrent record review, the MDS Supervisor stated that an MDS nurse had completed the care plan, confirmed that the resident did not have neurogenic bladder, and acknowledged that this diagnosis should not have been included. In a separate interview, the DON also confirmed that the resident did not have a diagnosis of neurogenic bladder and that its inclusion in the care plan was incorrect, stating the facility was responsible for ensuring the accuracy of residents’ medical records.
Delayed Release of Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide timely access to medical records for a resident who had been discharged with chronic kidney disease. The resident's legal representative submitted a written request for the resident's medical records, which was received by the Medical Records Director (MRD) on August 12, 2025. According to facility policy, records should have been released within 48 hours (two working days) of the request. However, the MRD forwarded the request to the facility's legal department, and the facility did not respond until September 8, 2025, resulting in a 27-day delay. The MRD confirmed that this delay did not comply with the regulatory requirement or facility policy for timely release of records.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale for the discharge of a resident who had been admitted with diagnoses including spinal fusion and depression. Record review showed that, as of June 1, the resident was recommended for follow-up imaging and was noted to benefit from continued care. Despite this, a Notice of Proposed Transfer/Discharge was issued, and subsequent documentation did not provide clinical justification that the resident no longer required facility services or that discharge was in the best interest of the resident's health and safety. Progress notes later stated the resident was independent and cleared for discharge, but lacked supporting clinical rationale from the physician. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, and Director of Nursing, confirmed that discharge planning began with a physician order, but the medical record did not reflect the necessary assessment or documentation supporting discharge readiness. The facility's policy required that the basis for transfer or discharge be documented in the resident's clinical record by the attending physician, which was not done in this case.
Failure to Use PPE During G-Tube Medication Administration for Residents on Enhanced Barrier Precautions
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to implement required infection control practices for two residents who were on Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters, feeding tubes, and wounds. Both residents had care plans and physician orders specifying that staff must use gowns and gloves during high-contact care activities, including medication administration via G-tube. During observations, LVNs were seen entering the residents' rooms and administering medications through G-tubes without wearing the required isolation gowns, despite the established protocols and documented requirements in the residents' records. Interviews with the involved LVNs confirmed that they were aware of the need to wear isolation gowns but failed to do so, with one stating she forgot and the other acknowledging the requirement to protect residents and prevent infection spread. The Infection Preventionist also confirmed that staff are expected to follow the designated precaution protocols and use appropriate PPE as indicated. Facility policy reviewed further supported the necessity of gowns and gloves for high-contact activities involving device care, such as feeding tubes.
Failure to Ensure Safe Serving Temperature of Hot Beverages Resulting in Resident Burns
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) served a hot beverage to a resident without checking the temperature to ensure it was within a safe serving range. The resident, who had a history of metabolic encephalopathy and multiple strokes resulting in right-sided hemiplegia, required supervision and set-up assistance with eating. Despite these needs, the CNA heated water in a microwave, prepared tea, and served it to the resident without verifying the temperature, contrary to facility policy. The incident resulted in the resident spilling the hot beverage on herself, causing significant burn injuries to her right breast and shoulder. Documentation and interviews confirmed that the resident experienced severe pain and required medical intervention, including an emergency room visit and follow-up wound care for second and third degree burns. The resident's care plan indicated a need for assistance with eating, and staff interviews revealed that the CNA was unaware of the requirement to check beverage temperatures before serving, while another CNA confirmed that such checks were part of their training and policy. Facility policies reviewed specified that hot beverages must be served at or below 155°F and that temperatures should be measured with a calibrated thermometer prior to service. The Director of Nursing confirmed that the CNA did not follow this policy, leading to the resident's injury. The resident recalled not being warned about the hot beverage and did not remember if the spill was caused by staff or occurred after she awoke from a brief sleep.
Failure to Assess, Monitor, and Follow Up on Skin Injuries and Changes
Penalty
Summary
Three residents experienced failures in assessment, monitoring, and follow-up of skin conditions and injuries. One resident, with a history of metabolic encephalopathy and diabetes, sustained burn injuries from a hot beverage spill. Upon return from the hospital, there was no evidence that treatment for the burns was initiated or monitored for several days, and a follow-up appointment with a burn specialist, as recommended by the hospital, was not arranged in a timely manner. Documentation gaps were noted, and staff interviews confirmed that the treatment nurse was not informed of the incident until four days later, delaying necessary wound care and evaluation. Another resident, with dementia, diabetes, and on long-term aspirin therapy, developed significant bruising on both hands. The skin changes were identified by a CNA and reported to nursing staff, but there was no documented assessment, monitoring, or referral to a physician for further evaluation and treatment. The care plan and physician orders required monitoring for signs of bleeding and prompt reporting, but these steps were not followed. Staff interviews confirmed that the bruising was not properly assessed or documented, and the DON acknowledged that the required protocols were not adhered to. A third resident, with diabetes and peripheral vascular disease, had known diabetic ulcers on both feet. Over a two-week period, the size of the wounds increased, but this change in condition was not identified or communicated to the physician. Weekly wound documentation failed to note the progression, and staff interviews revealed that the increase in wound size should have been recognized as a change in condition and reported. The DON confirmed that the lack of timely communication and documentation could have led to a delay in appropriate care.
Failure to Ensure Timely Response to Resident Telephone Calls
Penalty
Summary
The facility failed to ensure that telephone calls for a resident were answered by staff, resulting in a lack of immediate access to the resident. During an unannounced visit, it was found that a resident with ALS, a progressive neurodegenerative disease, was unable to use her call light after it fell to the floor. She called out for assistance but received no response from staff. The resident then contacted a family member for help. The family member reported making multiple unsuccessful attempts to reach facility staff by phone over an 11-minute period, eventually being transferred to the nurses' station without the call being answered or receiving a callback. Interviews with facility staff revealed that after the receptionist left at 9 p.m., incoming calls were transferred to the Registered Nurse Supervisor, who stated that calls might not be answered immediately if she was attending to resident care. Additional interviews with two other residents indicated that calls intended for them were also not forwarded. The administrator confirmed that the expectation was for calls to be answered and forwarded appropriately during and after office hours.
Failure to Timely Reorder Pain Medication Resulting in Unavailability
Penalty
Summary
The facility failed to ensure that Hydrocodone, a strong pain medication, was reordered in a timely manner for a resident with spinal stenosis of the lumbosacral region. The resident was admitted with diagnoses that included this condition, which can cause significant pain, numbness, and weakness. On review of the resident's progress notes, it was found that Hydrocodone 5-325 was not administered as prescribed because the medication was not available on a documented date. Interviews with a Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that the medication was not reordered when only seven pills remained, as required by facility policy. Both staff members acknowledged that there was no documentation of a timely reorder, and the facility's policy indicated that medications should be ordered in advance. This lapse resulted in the resident not receiving the physician-ordered pain management regimen due to the unavailability of the medication.
Delayed Provision of Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records within the required 48-hour time frame, as mandated by their policy. The legal representative of a resident, who had been admitted with diagnoses including a pressure ulcer and diabetes mellitus, requested the resident's medical records on January 16, 2025, with a valid authorization dated January 8, 2025. Despite the facility's policy requiring records to be provided within 48 hours, the records were not delivered until February 5, 2025, which was 14 business days after the request was made. The Medical Record Director (MRD) acknowledged receiving the request on January 16, 2025, and instructed the Medical Record Assistant to forward it to the facility's corporate legal team. However, the MRD did not follow up with the legal team until January 22, 2025, resulting in a delay. The Administrator confirmed that the facility's protocol required records to be provided within approximately 48 hours, but the legal representative did not receive the records until February 5, 2025. This delay had the potential to deny the resident representative access to review records and delay critical legal or medical decision-making for the resident.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered by the physician for three residents, leading to deficiencies in care. Resident #57, who was admitted with a Stage 4 pressure ulcer, did not have a dressing in place during an observation, despite orders to replace it as needed. The treatment nurse and CNAs were aware of the issue but failed to ensure the dressing was reapplied, and documentation was inconsistent with the actual care provided. Resident #63, also with a Stage 4 pressure ulcer, was found without a dressing during an observation. The CNA who provided care did not report the missing dressing to a nurse, and the treatment nurse expressed frustration over the lack of communication and follow-through. The facility's policy required that any nurse could replace the dressing if notified, but this protocol was not followed. Resident #160, at risk for pressure ulcers, had treatment orders for redness on the heels that were not consistently followed. The LVN responsible for the treatment admitted to signing the treatment administration record without actually providing the care, leading to missed treatments. The DON and Administrator acknowledged the expectation for staff to follow treatment orders and document care accurately, but these standards were not met in practice.
Facility Fails to Provide Safe Wheelchair for Resident
Penalty
Summary
The facility failed to provide a wheelchair in good condition for a resident, leading to a deficiency in maintaining a safe and homelike environment. The resident, who was admitted with conditions including hemiplegia and muscle wasting, was dependent on staff for transfers and used a wheelchair provided by the facility. Observations revealed that the wheelchair had multiple burn holes in the seat and a torn armrest with exposed foam, which posed a potential safety hazard. The resident's family confirmed that the wheelchair was provided by the facility, and the resident denied being a smoker, suggesting the damage was not self-inflicted. Interviews with facility staff, including a physical therapist, the Director of Maintenance, and the Administrator, revealed a breakdown in the process of ensuring wheelchairs were in good condition before being assigned to residents. The physical therapist acknowledged the wheelchair's poor condition but stated that cosmetic repairs were not their responsibility. The Director of Maintenance admitted that the wheelchair was not part of the facility's standard equipment and should not have been used. The Administrator confirmed that the wheelchair was mistakenly taken from a storage area meant for repairs and was not suitable for resident use. The Director of Nursing emphasized the expectation for equipment to be clean, well-maintained, and functional, highlighting the facility's failure to adhere to its own policies regarding wheelchair maintenance and safety.
Failure to Refer Resident for Level II PASRR Screening
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder was referred for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted with a negative Level I screening, which incorrectly indicated that the resident did not have a serious mental illness (SMI). Despite the resident's medical history and hospital records indicating a diagnosis of bipolar disorder, the facility did not identify this as an SMI and did not refer the resident for the necessary Level II PASRR screening. Interviews with facility staff revealed a lack of awareness and oversight in the PASRR screening process. The MDS Coordinator, responsible for checking the accuracy of PASRR screenings, was unaware that the resident's Level I PASRR was inaccurate. The Director of Nursing stated he was not involved in the PASRR process, and the Administrator indicated that the Admission Director and MDS Coordinator were responsible for ensuring the accuracy of PASRR screenings. This oversight led to the failure to identify and refer the resident for appropriate mental health services.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who required assistance with activities of daily living. The resident, who had a medical history of hemiplegia and hemiparesis following a stroke, was observed with long and dirty fingernails. Despite the resident's request for nail trimming, the staff did not fulfill this need, citing a lack of available nail trimmers. The resident had previously purchased nail trimmers, but they were taken by the staff and not used to trim the resident's nails. Interviews with facility staff revealed a lack of communication and awareness regarding the availability of nail trimmers. Certified Nurse Aides and a Licensed Vocational Nurse were unaware of the resident's need for nail care, and the Director of Nursing and Administrator stated that nail trimmers were available in the utility room. However, the staff failed to locate and use them, resulting in the resident's unmet need for personal hygiene care.
Failure to Administer Respiratory Treatments as Ordered
Penalty
Summary
The facility failed to provide respiratory breathing treatments as ordered by the physician for Resident #15, who was diagnosed with chronic obstructive pulmonary disease (COPD). The resident was supposed to receive DuoNeb treatments every six hours for seven days, but the order was incorrectly transcribed into the electronic health record as every six hours every seven days. This transcription error led to the resident receiving the treatment only once since the order was initiated in December 2024. Observations and interviews revealed that the nebulizer machine was not readily accessible, being covered by personal items, and the medication cannister and tubing were dated 12/30/2024, indicating infrequent use. Despite the resident's complaints of shortness of breath, cough, and congestion, the treatments were not administered as frequently as ordered. The respiratory therapist renewed the order on 01/02/2025 but did not correct the scheduling error, resulting in continued inadequate treatment. Interviews with staff, including LVNs and the Director of Nursing, highlighted a lack of verification and double-checking of the orders entered into the electronic health record. The Director of Nursing and the Administrator acknowledged that the orders should have been verified and checked by another nurse to ensure accuracy. The failure to provide the prescribed respiratory care was due to a combination of transcription errors, oversight in order verification, and inadequate monitoring of the resident's treatment schedule.
Failure in Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. The facility's policy on wound care and the CDC's recommendations for hand hygiene were not followed by the staff. Specifically, during the care of Resident #57, the Treatment Nurse and Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before proceeding with wound care. This resulted in the application of wound treatment with potentially contaminated gloves. Similarly, for Resident #63, the staff did not adhere to proper hand hygiene protocols. The Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before assisting with wound care. The Treatment Nurse also failed to perform hand hygiene between glove changes while treating the resident's sacral wound and an additional open area on the resident's back. These actions were contrary to the facility's policy and CDC guidelines, which emphasize the importance of hand hygiene before and after glove use and between different care tasks. Interviews with the staff, including the Treatment Nurse, Certified Nurse Aides, Licensed Vocational Nurses, the Director of Nursing, and the Administrator, revealed a lack of adherence to hand hygiene protocols. The staff acknowledged the need for hand hygiene before and after care and between glove changes, but their actions during the observed care did not reflect this understanding. The deficiency highlights a significant lapse in infection prevention and control practices within the facility.
Failure to Reassess and Monitor Low Blood Pressure
Penalty
Summary
The facility failed to reassess and monitor the vital signs of a resident who was experiencing low blood pressure, which was initially recorded at 65/49. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been admitted with diagnoses including sepsis and enterocolitis, showed a change in condition on November 5, 2024, when abnormal vital signs were noted. Despite receiving an order to transfer the resident to a hospital for further evaluation, there was no documentation of any reassessment or monitoring of the resident's blood pressure while waiting for the transfer. Interviews with the Director of Nursing and nursing staff revealed that the licensed nurse did not recheck the resident's blood pressure after the initial low reading, despite acknowledging that it should have been done. The facility's policy required documentation of changes in a resident's condition, but there was no record of reassessment or interventions provided to the resident. This lack of action and documentation could have delayed prompt response to the resident's condition.
Inadequate Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to implement proper infection control practices for a resident diagnosed with Clostridium Difficile (C. diff), a highly contagious bacteria. The resident was readmitted to the facility with enterocolitis due to C. diff and was placed on contact precautions. However, during an observation and interview, it was noted that disposable equipment, such as a stethoscope and sphygmomanometer, was not readily available for the resident in isolation. This lack of designated disposable equipment was confirmed by a Certified Nursing Assistant (CNA), a Registered Nurse (RN), the Infection Preventionist (IP), and the Director of Nursing (DON), all of whom acknowledged that such equipment should be available to prevent the spread of infection. The facility's policy and procedure documents, including those titled 'Clostridium Difficile' and 'Isolation-Categories of Transmission Based Precautions,' emphasize the importance of using dedicated equipment for residents on transmission-based precautions to prevent the transmission of infections. Despite these guidelines, the facility did not ensure that the necessary disposable equipment was available for the resident, increasing the risk of spreading the infection to other residents and staff. This oversight highlights a deficiency in the facility's infection prevention and control program.
Failure to Assist Legally Blind Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident, who was legally blind and had multiple medical conditions including type 2 diabetes mellitus, anxiety disorder, coronary artery dissection, and hypertensive heart disease. The resident's care plan indicated a need for assistance with feeding due to her inability to read the menu and her risk for aspiration related to difficulty swallowing. Despite these documented needs, during an unannounced visit, it was observed that a staff member placed the resident's lunch tray in front of her and left the room without providing the required assistance. Interviews conducted with the resident, a CNA, an RN, and the DON revealed a lack of adherence to the facility's policy on meal assistance. The resident expressed her inability to read the menu and her reliance on others to inform her about the meals. The CNA admitted to not knowing if the resident was aware of what was being served, while the RN acknowledged that assistance should be provided to someone who is blind. The DON confirmed that assistance should have been given to the resident, as per her care plan and the facility's policy, which mandates that residents receive meal assistance tailored to their individual needs.
Delayed Medical Records Requests
Penalty
Summary
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as stipulated by their policy and procedure. The process for obtaining medical records involved the requestor filling out a form, which was then sent to the corporate office for approval. This process was confirmed by both the Medical Records Assistant and the Medical Records Director, who stated that it typically took one to two weeks to fulfill a request. This delay was attributed to the medical records department being short-staffed, which resulted in the department falling behind in processing requests. The deficiency was identified during an unannounced visit to the facility, where it was found that requests for medical records for four residents were pending approval at the corporate office. These requests had been received between August 12 and August 20, 2024, but had not been fulfilled within the required timeframe. The Interim Administrator acknowledged that the medical records department was expected to complete requests within 48 hours, as per the facility's policy. The facility's policy, revised in November 2009, stated that residents could access their records within 48 hours of a request, excluding weekends and holidays.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for one of the sampled residents, identified as Resident 3. During an unannounced visit, it was observed that Resident 3, who has Alzheimer's Disease, was in bed with the call light clipped to her pillowcase and hanging off the left side of her bed, making it inaccessible. A Licensed Vocational Nurse (LVN) confirmed the call light was out of reach and admitted it was due to not repositioning the call light after the resident was repositioned. The Director of Nursing stated that the expectation is for nursing staff to ensure call lights are always within reach of residents. The facility's policy, revised in September 2022, also indicates that call lights should be accessible to residents when in bed.
Pesticide Application Conducted with Resident Present in Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident when pest treatment was conducted while the resident was inside the room. On August 20, 2024, an observation was made of the resident lying in bed, unresponsive to interview questions. The Maintenance Supervisor admitted to spraying pesticide inside the resident's room while the resident was present, stating that the spray was not toxic to humans and only a small amount was used. The Maintenance Supervisor did not move the resident or consult with the visitor present at the time before proceeding with the pesticide application. The facility's Administrator stated that the protocol for spraying pesticides in resident rooms includes moving the resident out and deep cleaning the room afterward. The Administrator expected the Maintenance Supervisor to notify nursing staff before spraying so that residents could be relocated. However, Registered Nurse 1 was unaware of the pesticide application in the resident's room and would have expected to be informed to move the resident out to prevent direct exposure. The facility's policy on maintaining a homelike environment emphasizes providing a safe, clean, and comfortable setting, which was not adhered to in this instance.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with an existing stage 4 pressure ulcer was repositioned at least every two hours, as outlined in the resident's care plan. Observations on a specific day revealed that the resident remained in the same position on her back with the head of the bed elevated at 30 degrees for over three hours, from 9:50 a.m. to 12:59 p.m. This was contrary to the care plan's directive to turn and reposition the resident at least every two hours to minimize skin impairment. During an interview, a CNA assigned to the resident admitted to not repositioning the resident during the observed period, citing being busy as the reason. The facility's policy on repositioning, revised in May 2013, emphasizes the importance of repositioning immobile residents every two hours to prevent skin breakdown and promote circulation. The Director of Nursing confirmed that the expectation is for nursing staff to adhere to the care plan's repositioning schedule.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two of four resident rooms, as observed during an unannounced visit. In one room, a brown-colored splatter of an unknown substance was found on the window wall, dirty gloves were on the floor outside of the trash can, and three dried drops of blood were on the floor near Bed B. A resident in this room confirmed that the blood was from their toe but could not specify how long it had been there. The housekeeper admitted that she had not yet cleaned this room on the day of the observation. In another room, trash, food crumbs, and dust were found behind the headboards of Beds A and B, despite the housekeeper stating that she had already cleaned the room. The housekeeper acknowledged that she had not cleaned behind the headboards, which she should have done. A Registered Nurse verified the unclean conditions and expressed that the room should have been cleaned better. The facility's policy, titled 'Homelike Environment,' emphasizes providing a clean, sanitary, and orderly environment, which was not adhered to in these instances.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative, as required by regulations. This deficiency was identified during a review of the records for a resident who was admitted with diagnoses including depression and schizoaffective disorder. The resident was discharged to an acute hospital for psychiatric evaluation and medication management, but there was no documentation indicating that a written notice of transfer was provided to the resident or their representative. The Notice of Proposed Transfer/Discharge form was incomplete, with no entries for the name or relationship of the person notified, and no indication that it was mailed to a representative. During interviews, the Director of Nursing (DON) confirmed that the licensed nurses are responsible for providing the Notice of Proposed Transfer/Discharge form to the resident upon transfer. However, the form was neither signed nor dated by the resident, indicating that the notice was not acknowledged. The DON acknowledged that the licensed nurse who facilitated the transfer should have ensured the resident received a written notice. The facility's policy, revised in December 2016, mandates that residents and their representatives be notified in writing of the reasons for transfer or discharge and the facility's bed-hold policy.
Violation of Resident's Personal Space and Dignity
Penalty
Summary
The facility failed to protect a resident's personal space and dignity when a Certified Nursing Assistant (CNA) touched the resident on the shoulder near her breast without her consent, making her uncomfortable. The incident was reported by the resident, who stated that the CNA entered her room, started rubbing her shoulder, and moved down to her breast. The resident did not ask for this contact and felt uncomfortable, leading her to remove the CNA's hand and tell him to stop. The resident's medical records indicated she had no cognitive impairments and was alert and oriented at the time of the incident. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) confirmed the resident's account. The CNA admitted to touching the resident without asking for permission, and the DON acknowledged that this action violated the resident's rights to respect and dignity. The facility's policy on Resident's Rights, which mandates treating all residents with kindness, respect, and dignity, was not followed in this instance.
Failure to Re-evaluate Discharge Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to re-evaluate and modify Resident A's discharge plan when the resident developed a Stage 4 pressure injury. Resident A, who had paraplegia, was admitted to the facility with a history of skin conditions. On May 19, 2023, Resident A's fragile scar tissue on the coccyx reopened, resulting in a Stage 4 pressure ulcer. Despite this significant change in condition, the facility did not update the discharge plan or communicate the presence of the pressure ulcer to the accepting assisted living facility, which does not provide extensive medical care. The Assisted Living Assistant Administrator (AA) stated that she was not informed about Resident A's pressure ulcer and would not have admitted the resident if she had known about it. The AA confirmed that the facility staff had assured her that Resident A had no wounds. Consequently, Resident A was discharged to the assisted living facility on May 28, 2023, and had to be transferred to an acute hospital two days later due to the worsening of the pressure ulcer. Interviews with the facility's staff, including the Registered Nurse (RN), Director of Nursing (DON), and Social Service Assistant (SSA), revealed that there was a lack of communication and documentation regarding Resident A's pressure ulcer. The SSA, responsible for discharge planning, was unaware of the pressure ulcer and did not inform the assisted living facility. The DON acknowledged that the discharge plan should have been re-evaluated and updated, and the RN confirmed that the Interdisciplinary Team (IDT) should have coordinated the discharge plan modification. The facility's policy on transfer and discharge was not followed, leading to an unsafe discharge for Resident A.
Failure to Properly Manage and Account for Resident's Personal Belongings
Penalty
Summary
The facility failed to properly manage and account for the personal belongings of Resident A, leading to a deficiency in honoring the resident's right to a dignified existence and self-determination. Resident A, who was discharged from the facility, reported missing several personal items including groceries worth $193, dentures, contact lenses, underwear, and a speaker. The facility's documentation process for personal belongings was found to be inadequate, as the Inventory of Personal Effects form was not properly filled out or signed by staff upon both admission and discharge. This lack of documentation and accountability was confirmed through interviews with various staff members, including the Medical Records Director, Licensed Vocational Nurse, Registered Nurse, and Social Service Director, all of whom acknowledged the failure to follow the facility's policies and procedures for managing personal belongings. The report highlights that the facility's policy required the inventory of personal belongings upon admission and discharge, but this was not adhered to in Resident A's case. The staff failed to document and verify the items returned to Resident A or her representative, leading to the loss of personal property. Interviews with staff members revealed that the process for managing personal belongings was not consistently followed, and there was no proper documentation or signature to confirm the items returned. This failure in procedure resulted in Resident A feeling disrespected and undignified due to the mishandling of her personal property.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide care and services for activities of daily living (ADLs) for a resident when feeding assistance was not provided according to the physician's orders and plan of care. The resident, who had diagnoses including diabetes mellitus and dementia, was admitted to the facility with fluctuating capacity to understand and make decisions. The resident had a physician's order for RNA feeding assistance for breakfast, lunch, and dinner, but this assistance was not consistently provided, leading to a significant weight loss of five pounds in one month. Observations and interviews revealed that the resident often consumed only 0-25% of her meals and was mostly provided with set-up or clean-up assistance rather than the required feeding assistance. Staff members, including CNAs and LVNs, acknowledged that the resident would benefit from RNA feeding assistance to increase meal intake but admitted that such assistance was not consistently provided. The resident's family member also reported that meal trays were often left uncovered without staff present to assist, and the family member had to step in to help when available. The facility's policy indicated that residents on the Restorative Dining Program should receive physical prompts and verbal cues to facilitate maximum potential in feeding. However, the documentation and staff interviews confirmed that the resident did not receive the necessary feeding assistance as ordered, contributing to her poor oral intake and weight loss. The interim Director of Nursing and other staff members acknowledged the deficiency and the importance of providing the ordered feeding assistance to prevent further weight loss.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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