Crestwood Manor - 104
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 1130 Monaco Court, Stockton, California 95207
- CMS Provider Number
- 05A340
- Inspections on file
- 25
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Crestwood Manor - 104 during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, violent behavior, and a documented history of intrusive, assaultive, and socially inappropriate behaviors was on 1:1 supervision due to escalating sexually inappropriate behavior. Despite continuous restlessness, agitation, pacing, and ineffective redirection by a CNA, PRN Ativan ordered for behavior management was not successfully administered before the resident used the bathroom, exited, and crossed into a roommate’s personal space to smear feces on the sleeping roommate’s face. Multiple nurses later confirmed that 1:1 supervision required staff to remain within arm’s length, anticipate escalation, and prevent entry into other residents’ space, and that PRN medication should be given promptly when nonpharmacological interventions fail. The facility’s own policies on assaultive behavior management and elder/dependent adult abuse, which guarantee freedom from physical abuse by anyone, were not effectively implemented, resulting in a failure to protect a resident from physical abuse by another resident.
A resident with a history of falls and a self-care deficit developed a fear of falling and refused to walk, but the facility did not update the care plan to address these issues. Despite PT recommendations for staff assistance and documentation of declining ambulation, staff confirmed that the resident's fear and refusal were not incorporated into the care plan, contrary to facility policy.
A resident experienced a decline in ambulation ability after staff failed to consistently document walking attempts or refusals, did not always provide recommended supervision, and did not update the care plan to address the resident's fear of falling. Despite a history of falls and a physical therapy recommendation for supervised ambulation, the care plan lacked interventions for the resident's behavioral barriers, and ambulation assistance was inconsistently provided and recorded.
Surveyors identified multiple deficiencies in food storage, preparation, and equipment sanitation, including moldy produce, improperly labeled and undated food items, ice buildup in the walk-in freezer, wet-stacked dishes, a dirty and damaged can opener, stained serving ware, deeply grooved cutting boards, and missing air gaps in plumbing for the ice machine and produce sink. These issues were confirmed by dietary and maintenance staff during interviews.
The facility did not ensure that four residents' rights regarding advance directives and code status were properly documented and protected. In several cases, signed Advance Directives or documentation of discussions were missing from both electronic and physical charts, and staff were unable to locate or verify these critical documents. For one resident, code status was not documented in either the EHR or physical chart, leading staff to rely on chart label color to determine status. These failures were confirmed by interviews with staff and residents.
Two residents experienced deficiencies in nutritional care: one resident with significant weight loss and swallowing difficulties did not receive a speech therapy referral despite ongoing meal refusals and poor intake, while another resident with diabetes was not offered a timely replacement meal after refusing and discarding her lunch, contrary to facility policy. These actions resulted in inadequate nutrition for both residents.
The facility did not provide appropriate vegetarian meals for four residents with documented vegetarian diet orders or preferences. Instead, staff substituted fruit and cottage cheese plates for main entrees containing meat, resulting in meals with significantly less protein and calories than the regular menu. Dietary staff and the RD confirmed that these substitutions did not meet residents' nutritional needs, despite facility policy and state law requiring balanced vegetarian options.
The facility failed to maintain proper infection control by storing clean supplies next to hoppers used for waste disposal in utility rooms, allowing a nurse to bring a supply bucket for insulin administration into multiple resident rooms without cleaning, and not cleaning medication carts and pill cutters after use. Additionally, kitchen vent covers above food prep areas had rust, peeling paint, and debris, with maintenance and dietary staff confirming these unsanitary conditions.
Nursing staff did not have access to drug information resources, such as reference books or online guides, when administering medications. An LPN was unaware of specific administration instructions for Linzess, and staff confirmed that neither the medication cart nor the medication room contained drug reference materials. The DON acknowledged that drug information resources were not available for staff use, contrary to facility policy.
A resident with a history of convulsions did not receive accurate fall risk assessments, as multiple assessments failed to document seizures as a predisposing factor and did not reflect the resident's use of antiseizure medication. These inaccuracies were confirmed by an LPN and acknowledged by the DON, with the facility's policy requiring accurate assessment and documentation to guide fall prevention interventions.
A resident with chronic pain related to embolism and thrombosis experienced ongoing, inadequately managed pain despite frequent requests and increased use of PRN acetaminophen. Staff did not notify the physician about the ineffective pain regimen, and no individualized care plan for pain was developed or implemented, contrary to facility policy. These failures resulted in the resident experiencing unnecessary pain and reduced participation in daily activities.
Three residents experienced deficiencies in medication management, including the long-term use of a PPI without reassessment and the absence of clear monitoring parameters for insulin and blood sugar levels in two diabetic residents. The consultant pharmacist and DON did not identify or address these issues, and medication orders lacked specific guidance for nursing staff on when to intervene for abnormal blood sugar readings.
The facility had a medication error rate of 9%, with errors including improper eye drop administration, giving Linzess after a meal instead of on an empty stomach, and inaccurate MAR documentation for a held blood pressure medication. Staff failed to follow standard practices, manufacturer instructions, and facility policies during medication administration and documentation.
Surveyors found that medications were improperly labeled and stored, with discontinued and unlabeled drugs kept in active storage areas, hazardous medication spills present in a medication cart, and sticky residues in pre-pour bins. Supplies and discontinued medications were stored under sinks, and medication refrigerators were not maintained within the required temperature range. Staff interviews revealed uncertainty about proper procedures, and facility policies were not consistently followed.
A resident with schizophrenia and anxiety was transferred to an acute care hospital for stabilization but was not permitted to return to the LTC facility. Despite being stable for discharge, the facility refused readmission, did not provide required bed-hold or discharge notices, and failed to re-evaluate the resident's return. The resident remained at the hospital for five days, awaiting placement elsewhere.
The facility failed to provide dental services for two residents, resulting in unmet dental needs and potential health complications. One resident had not seen a dentist since admission despite having missing teeth and cavities, while another resident waited seven months for recommended dental treatment.
A CNA failed to ensure a resident's dignity and safety by standing over her while assisting with a meal, contrary to the facility's policy and the resident's care plan, which required close supervision due to dementia, a left-hand contracture, and schizophrenia.
A facility failed to ensure a resident's call light was accessible, as it was found on the floor and not within reach. The resident, who had ataxia and a high fall risk, was dependent on staff for basic care. Staff acknowledged that the call light should have been accessible at all times, and the facility's policy was not followed.
A facility failed to document an evaluation or assessment for a resident's use of a lap buddy after multiple falls. The resident was observed with the lap buddy secured, and staff confirmed its use without proper medical documentation or periodic assessments, leading to a deficiency in ensuring the resident was free from physical restraints without proper evaluation.
A resident admitted with dental issues did not receive timely dental care due to inaccurate MDS assessment documentation. The resident reported missing and broken teeth, but the facility failed to arrange a dental consultation, leading to potential health complications.
The facility failed to provide necessary oral hygiene supplies and care to a resident, resulting in poor oral hygiene and potential health complications. Despite claims of refusal, there was no documentation to support this, and the resident's personal hygiene basket was missing.
The facility failed to ensure that two residents were free from potential accidents and injury. One resident's fall mat was not laid out as per the care plan, and another resident's bed side rails were found in an unsafe position, creating a tripping hazard. The facility's policies and procedures for safety were not followed.
The facility failed to protect a resident from physical abuse by another resident, resulting in emotional distress and a physical injury. The incident occurred when one resident, with a history of assaultive behavior, punched another resident in the nose during an altercation in their shared bathroom. Staff intervened and moved the aggressive resident to a different room.
Failure to Prevent Resident-to-Resident Physical Abuse During 1:1 Supervision
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident with a known history of intrusive, assaultive, and socially inappropriate behaviors. Resident 1 was admitted with schizoaffective disorder bipolar type, cataract, presbyopia, and anemia. Resident 2 was admitted with schizoaffective disorder bipolar type, violent behavior, and mild neurocognitive disorder with behavioral disturbance. Resident 2 had documented care plans for intrusive behavior, assaultive behavior, combative behavior, and socially inappropriate behavior, including a history of pacing, entering other residents’ rooms, becoming aggressive with redirection, and attempting to strike staff during oral medication administration. On the night of the incident, Resident 2 was on 1:1 supervision due to sexually and socially inappropriate behavior. CNA 1, who was assigned to provide 1:1 supervision, reported that Resident 2 was restless, agitated, pacing, and repeatedly leaving the room, and described these behaviors as acting weird. CNA 1 attempted redirection, advised Resident 2 to calm down, and encouraged Resident 2 to go back to sleep, but these nonpharmacological interventions were ineffective. CNA 1 stated she asked the nurse to give medication to help with Resident 2’s behavior, but Resident 2 initially refused. Despite ongoing uncontrolled behaviors that did not respond to redirection, medication to manage behavior was not successfully administered before the incident. At approximately 4 AM, Resident 2 used the bathroom and, upon exiting, walked toward Resident 1’s bed. Resident 2 approached the head of Resident 1’s bed, where Resident 1 was sleeping, and smeared feces on Resident 1’s face. The CNA yelled for help, and nursing staff responded. Progress notes and MAR review confirmed that Ativan by mouth was offered and refused, and Ativan by injection was administered to Resident 2 only after the incident. Multiple licensed nurses and the DON stated that 1:1 supervision required staff to remain within arm’s length or very close proximity to the resident, closely monitor for escalating behaviors, and intervene to prevent the resident from entering another resident’s personal space, and that when nonpharmacological interventions were ineffective, prescribed PRN medication should be administered promptly to prevent escalation. The facility’s policies on management/prevention of assaultive behavior and elder and dependent adult abuse stated that residents have the right to be free from physical abuse and that PRN medication may be offered when nonpharmacological interventions are ineffective, but Resident 1 nonetheless experienced unwanted physical contact with feces from Resident 2. The physical layout of the room placed Resident 1’s bed (Bed C) near the window and bathroom, with the head of the bed against the wall and the foot of the bed visible from the bathroom exit. Resident 2’s bed was in the middle (Bed B). On the date of the incident, Resident 2 had also been reported to have left paper towels with feces at the nurse’s station on two occasions and had previously sprayed CNAs with a shower hose. Staff interviews confirmed that Resident 2’s behaviors were escalating and that 1:1 supervision was in place for safety and behavior concerns. Despite this, Resident 2 was able to exit the bathroom, cross into Resident 1’s personal space, and smear feces on Resident 1’s face while Resident 1 slept, constituting physical abuse by another resident and a failure to protect Resident 1 from abuse as required by facility policy and regulation. Staff, including LN 1, LN 2, LN 3, and LN 4, acknowledged that Resident 2’s history of intrusive, anxious, pacing, aggressive, assaultive, and combative behaviors placed Resident 2 at risk for resident-to-resident altercations and that delays in administering ordered behavior-management medications could allow behaviors to escalate and increase safety risks. They also stated that 1:1 supervision required close proximity, continuous observation, and prevention of entry into other residents’ personal space. Nonetheless, during the period of escalating restlessness and agitation, Resident 2’s behavior was not effectively controlled, and the required level of supervision and timely pharmacologic intervention was not achieved before Resident 2 smeared feces on Resident 1’s face. This sequence of events led to the deficiency for failure to protect a resident from physical abuse by another resident. The facility’s Elder and Dependent Adult Abuse/Suspicion of a Crime policy stated that every resident has the right to be free from physical abuse with resulting physical harm, pain, or mental suffering, and that residents must not be subjected to abuse by anyone, including other residents. The Management/Prevention of Assaultive Behavior policy stated that when licensed staff assess that an individual is not responding to nonpharmacological interventions, PRN medication may be offered per physician order. Despite these policies and the known behavioral history and active 1:1 supervision status of Resident 2, the facility did not prevent Resident 2 from entering Resident 1’s personal space and smearing feces on Resident 1’s face while Resident 1 was sleeping, resulting in the cited deficiency for failure to protect residents from abuse.
Failure to Develop and Implement Care Plan for Resident's Fear of Falling and Refusal to Walk
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan addressing a resident's fear of falling and subsequent refusal to walk following multiple unwitnessed falls. The resident, who had a documented self-care performance deficit and was at risk for falls, experienced several unwitnessed falls in the bathroom and near her bed. Despite a physical therapy consult indicating the resident was unsafe to ambulate independently and required staff assistance at all times, documentation showed a decline in the resident's walking activity over several months. Staff provided some encouragement and supervision, but the resident continued to refuse to walk due to fear of falling. Interviews with facility staff, including a CNA and the DON, confirmed that the resident's fear of falling and refusal to walk were not addressed in the care plan. The Director of Staff Development also stated that such refusals and fears should be communicated and incorporated into the care plan to guide staff interventions. Review of the facility's care planning policy indicated that care plans should include measurable objectives, timeframes, and address resident refusals and psychosocial needs, but these elements were missing in this case.
Failure to Maintain Resident Ambulation Due to Inadequate Documentation and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained the ability to perform activities of daily living, specifically ambulation, without a documented medical reason for decline. Staff did not consistently document attempts to walk the resident or record refusals, and there was a lack of consistent supervision during ambulation as recommended by physical therapy. The care plan did not address the resident's fear of falling, despite this being identified as a barrier to participation in walking activities. The resident had a history of falls and was previously able to ambulate independently for short distances, as documented in the Minimum Data Set (MDS). Over time, the resident's ability to walk declined, and she began using a wheelchair. Interviews with staff revealed that the resident stopped walking due to fear of falling, and staff confirmed that there was no walker in her room. Documentation showed sporadic and inconsistent ambulation attempts, with staff sometimes providing assistance but not always following the recommended supervision or documenting refusals. The physical therapist noted that the resident was too fearful to participate in walking during evaluation and recommended psychiatric assessment before starting a rehabilitation program. However, the psychiatric evaluation did not address the resident's fear of falling, and the care plan was not updated to include interventions for this issue. Facility policies required documentation of ambulation and assistance as needed, but these were not consistently followed, contributing to the resident's decline in mobility.
Multiple Food Safety and Sanitation Deficiencies Identified in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations during a kitchen tour and interviews with dietary staff. Mold was found on red onions in the walk-in refrigerator, and other onions were cracked, bruised, and discolored. The Dietary Assistant Supervisor confirmed that storing molded food with non-molded food was unacceptable. Additionally, several food items in the kitchen and refrigerator lacked proper labeling, open dates, or expiration dates, and some labels were incomplete or missing the year. The Registered Dietician and Dietary Supervisor both stated that proper dating is necessary to ensure food safety and prevent the use of expired items. Further deficiencies were observed in the storage and maintenance of kitchen equipment and utensils. The walk-in freezer had significant ice buildup, preventing the door from closing and latching properly, which the Plant Maintenance Supervisor attributed to faulty hinges. Clean kitchen items were stacked while still wet, and a dirty plate was placed among clean dishes, which staff acknowledged could lead to bacterial growth. The fixed can opener was found with food particles, missing metal, and visible metal shavings, raising concerns about food contamination. Additionally, coffee mugs and pitchers were stained and deglazed, and cutting boards had deep grooves, all of which were confirmed by the Dietary Supervisor as not meeting expectations for cleanliness and safety. Plumbing issues were also identified, with the ice machine and fruit/vegetable preparation sink lacking required air gaps to prevent backflow contamination. Both the Plant Maintenance Supervisor and Plant Maintenance Assistant were unaware of the air gap requirement and confirmed the improper plumbing setup. These findings were supported by references to the facility's policies and the US FDA Food Code, which outline standards for food storage, equipment maintenance, and plumbing to ensure food safety for residents.
Failure to Document and Honor Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that four residents had their rights related to treatment choices, advance directives, and code status properly documented and protected. For one resident, the signed Advance Directive was not found in the chart, despite documentation in the EHR that the resident had been given copies and had signed the forms. The Social Services staff and Unit Clerk were unable to locate the paperwork in either the current or archived charts, and the resident herself was unsure if she had an Advance Directive in place. The Director of Nursing confirmed that the documentation should have been present in the chart as per facility policy. Another resident expressed a desire to formulate an Advance Directive, and the Social Services note indicated that the conservator was contacted. However, there was no follow-up documentation or acknowledgement form found in the chart, and the resident did not recall being offered the Advance Directive. The Social Services staff and Director of Medical Records both verified that the documentation was missing and should have been included in the resident's record. A third resident's chart did not contain documentation regarding an Advance Directive discussion, and the resident had refused the initial assessment due to anxiety. The Social Services staff acknowledged that no follow-up or documentation was completed. For a fourth resident, neither the electronic health record nor the physical chart contained documentation of the resident's code status, and staff relied on the color of the chart label to determine code status in the absence of formal documentation. The Director of Nursing and other staff confirmed that the code status should have been clearly documented in both the EHR and physical chart.
Failure to Maintain Adequate Nutrition and Timely Meal Replacement for Two Residents
Penalty
Summary
The facility failed to maintain adequate nutritional status for two residents. For one resident with a history of poor intake, meal refusals, and food pocketing, there was an 8-pound (5.8%) weight loss over one month. Despite the resident's ongoing issues with swallowing and refusal of pureed foods, no referral was made to a speech therapist, and interventions were limited to offering supplemental nutrition drinks, an appetite stimulant, and a pureed diet. Observations showed that the resident continued to refuse meals and consumed only a partial amount of a supplemental drink, resulting in insufficient caloric and protein intake. The resident's medical record indicated diagnoses including hypothyroidism, anxiety, depression, pain, and recent pneumonia. Nursing notes documented persistent meal refusals, pocketing, and spitting out food, with the resident expressing dislike for pureed foods. The Registered Dietitian had recommended an appetite stimulant and supplemental nutrition, but no further assessment or intervention for swallowing difficulties was initiated, as the facility lacked a therapy department and no physician order for a speech therapy consult was made. For another resident with diabetes, staff failed to offer a replacement lunch meal in a timely manner after the resident refused to eat and spilled her lunch tray during a behavioral episode. Although facility policy required staff to offer meal replacements at least twice following a refusal, the resident was only asked once and then not again. The DON confirmed that the resident should have been offered a replacement meal at least twice, but this did not occur, resulting in the resident not receiving adequate nutrition during that meal period.
Failure to Provide Adequate Vegetarian Diets
Penalty
Summary
The facility failed to provide a vegetarian menu for four residents who had physician orders or documented preferences for vegetarian diets. Observations and interviews revealed that the facility did not offer a dedicated vegetarian menu and instead substituted fruit and cottage cheese plates for residents avoiding animal products. Review of meal tickets and medical records confirmed that these residents had ongoing orders or preferences for vegetarian diets, some dating back several months or years. During multiple meal observations, residents on vegetarian diets were served meals that lacked adequate protein and calories compared to the regular menu, with one resident receiving only pureed vegetables and another receiving only fruit, cottage cheese, crackers, and a cookie bar. Staff interviews indicated a lack of understanding and implementation of vegetarian diet requirements, with dietary staff and CNAs confirming that fruit and cottage cheese were routinely substituted for main entrees containing meat. The Registered Dietitian acknowledged that these substitutions did not meet the nutritional needs provided by the regular menu and noted that a vegetarian option was available through the menu company but was not being utilized. Facility policy documents and state law require the provision of balanced vegetarian or plant-based meals, but these were not being followed, resulting in residents receiving nutritionally inadequate meals.
Infection Control Failures in Utility Rooms, Medication Handling, and Kitchen Ventilation
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices in several key areas. In three utility rooms, clean supplies such as gloves, N95 masks, blood pressure apparatus, wound care supplies, and residents' personal items were stored in close proximity to hoppers used for disposal of blood or body fluids, without any clear separation between clean and dirty areas. The Infection Preventionist confirmed that this arrangement could lead to contamination of clean supplies, which could then be used for resident care. During medication administration, a nurse was observed bringing a bucket containing clean supplies for insulin administration and blood glucose testing into a resident's room. After use, the bucket was returned to the medication cart without any cleaning or sanitizing, despite being used in multiple resident rooms. Both nursing staff and the Director of Nursing acknowledged that this practice could result in contamination of supplies shared among residents. Additionally, the medication cart was found to have brownish residues and sticky spills in the pre-pour medication bins, and a pill cutter stored in the cart had white powder-like residue inside the lid, both of which were not cleaned after use. In the kitchen, three ceiling vent covers above food preparation areas were observed to have rust, flaking, peeling, and missing paint, with visible dust and debris. The Plant Maintenance Supervisor and Dietary Supervisor confirmed these conditions and acknowledged that the vents were not maintained in a manner that would prevent contamination of food. The facility's own policies and federal guidelines require that such areas be kept clean and in good repair to prevent the risk of contamination.
Lack of Drug Information Resources for Nursing Staff
Penalty
Summary
The facility failed to provide drug information resources, such as a drug reference book or online access, for nursing staff to consult when administering medications. During interviews and record reviews, multiple nursing staff members, including a licensed nurse, a licensed psychiatric technician, and a registered nurse supervisor, confirmed that they did not have access to drug information resources in the medication cart, medication room, or via the internet. One nurse was unaware of the specific administration instructions for Linzess, a medication used to treat complicated constipation, and did not know it should be given on an empty stomach 30 minutes before meals. Staff also indicated that the Medication Administration Record (MAR) did not provide this information. The Director of Nursing confirmed that the facility did not have printed or online drug resources available for nursing staff. Review of the facility's policy on medication reference sources indicated that such resources should be maintained and accessible at each nursing station, but this was not being followed at the time of the survey.
Inaccurate Fall Risk Assessments for Resident with Seizure History
Penalty
Summary
The facility failed to ensure that a resident with a history of convulsions received accurate post-fall and comprehensive fall risk assessments. Multiple fall risk assessments for the resident incorrectly indicated that there were no predisposing factors such as seizures, despite the resident's admission record documenting a history of seizures and ongoing use of antiseizure medication (Keppra). Additionally, the assessments did not accurately reflect the resident's medication regimen, which included both antiseizure and psychotropic medications. These inaccuracies were confirmed by a licensed nurse during a review of the resident's clinical record. The Director of Nursing acknowledged that the fall risk assessments were not completed accurately and emphasized the importance of these assessments in determining fall risk and developing appropriate interventions. The facility's policy requires that fall risk assessments be completed upon admission and that relevant findings and interventions be documented and updated in the care plan. The failure to accurately complete these assessments potentially resulted in a subsequent fall for the resident 14 days later, as the resident's fall risk was not properly identified or addressed.
Failure to Provide Adequate Pain Management and Develop a Person-Centered Pain Care Plan
Penalty
Summary
A resident with a history of chronic embolism and thrombosis of the lower extremities experienced ongoing pain, fluctuating between 5 and 8 out of 10 on the pain scale, primarily in the bilateral anterior thigh radiating to the lower extremities. The resident reported that the prescribed pain medication, acetaminophen, was not effective in relieving the pain, which impacted daily activities and participation in group and social events. Staff interviews confirmed that the resident frequently requested pain medication, particularly in the mornings, and that the frequency of PRN acetaminophen administration had increased significantly from 4 doses in February to 28 doses in April. Record reviews and staff interviews revealed that despite the increased use of PRN pain medication and the resident's ongoing complaints of pain, there was no evidence that the effectiveness of the pain management regimen was evaluated or that the physician was notified about the lack of pain control, as required by facility policy. Both the licensed nurse and the DON acknowledged that the increase in PRN medication indicated ineffective pain management, and that the physician should have been notified to consider alternative or routine pain management strategies. The facility's pain management policy specifically required physician notification and reassessment when pain control was inadequate. Additionally, the resident did not have a comprehensive, person-centered care plan addressing pain management, despite being prescribed pain medication and having active pain symptoms. Staff confirmed that the absence of a care plan for pain meant that measures to manage the resident's pain and discomfort were not identified or implemented. The DON acknowledged that this failure was not in accordance with facility policy, which required individualized care plans for residents experiencing pain, including specific interventions and measurable objectives.
Failure to Reassess Long-Term Medication and Lack of Safe Monitoring Parameters for Diabetic Medications
Penalty
Summary
The facility failed to ensure safe medication use practices for three residents by not reassessing the continued need for long-term medication and by not providing clear monitoring parameters for diabetic medications. One resident had been receiving Protonix, a proton pump inhibitor (PPI), daily for several years to treat GERD, but there was no documented reassessment of the ongoing need for this medication. The resident's care plan and physician progress notes did not address the continued use of Protonix, and the consultant pharmacist did not make recommendations regarding the long-term use despite being aware of FDA warnings about risks associated with prolonged PPI use. The physician stated he was not prompted to review the medication and acknowledged there were no active issues requiring its continuation. Two other residents were receiving multiple medications for diabetes, including insulin, but their medication orders lacked specific parameters for nursing staff to follow in response to abnormal blood sugar readings. Orders included instructions for blood sugar monitoring and the use of a reversal agent for hypoglycemia, but did not specify what constituted high or low blood sugar levels that would require intervention before the resident became unresponsive. The consultant pharmacist did not identify the lack of parameters, and the DON agreed that having such parameters would be a safe practice, especially given the use of other medications that could affect blood sugar levels. During medication administration observations, it was noted that nurses administered insulin without clear guidance on when to hold the medication or notify a physician based on blood sugar results. The facility's policy referenced notifying a physician for abnormal blood sugar results, but the actual orders for these residents did not provide the necessary parameters. Both the physician and nursing staff acknowledged the absence of these safety measures and indicated that parameters would be beneficial for safe medication administration.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 32 opportunities. These errors involved three residents and included improper administration techniques, failure to follow manufacturer instructions, and inaccurate documentation in the Medication Administration Record (MAR). One resident received ophthalmic medication, but immediately after administration, used a tissue to squeeze and wipe the eyes, contrary to standard practice. The staff member present acknowledged that the resident should not have wiped the eye drops from the eyes in this manner. Another resident was administered Linzess, a medication intended to be given on an empty stomach, after breakfast. The nurse administering the medication was unaware of the specific administration requirements, and the MAR did not include instructions to give the medication before meals or on an empty stomach. A third resident had a blood pressure medication, metoprolol, held due to low systolic blood pressure as per physician orders. However, the MAR was inaccurately documented, indicating the medication was given when it was actually held. The nurse confirmed that there was no documentation to reflect that the medication was withheld, and the Director of Nursing agreed that the documentation should have accurately indicated when a medication was held. Facility policies reviewed required proper administration techniques, adherence to manufacturer instructions, and accurate documentation when medications are held.
Deficient Medication Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices across several medication rooms and carts. Unlabeled and discontinued medications, including Linzess and Gavilyte-G, were found stored in active medication storage areas in two medication rooms. Some medication bottles lacked full pharmacy labels, displaying only small labels on the caps, and staff were unable to explain the absence of proper labeling. Discontinued or one-time use medications were not removed from active storage, contrary to facility expectations, and staff interviews confirmed uncertainty about proper storage procedures. In one medication cart, a hazardous liquid medication, Valproic Acid, was found with visible spills on the outer surface of the bottle. Staff acknowledged that while gloves are typically used to administer this medication, there was a risk of inadvertent skin contact when searching for other medications in the cart. Additionally, another medication cart contained pre-pour medication bins with sticky, brownish spills and broken sections, and staff were unsure of the origin of the residue or the last time the bins were cleaned or replaced. Further deficiencies were observed in the storage of supplies and discontinued medications under sinks in two medication rooms, where staff could not provide a rationale for this practice. Medication refrigerators were also found to be outside the recommended temperature range, with one refrigerator above and another below the accepted range. Staff interviews confirmed awareness that improper storage temperatures could affect medication efficacy, and facility policies required medications to be stored at appropriate temperatures and for discontinued or expired medications to be separated and destroyed or returned according to guidelines.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after being transferred to an acute care hospital for stabilization. The resident, who had been at the facility for nearly nine months, was diagnosed with schizophrenia and an anxiety disorder. On the day of the incident, the resident exhibited aggression and was administered lorazepam intramuscularly. Subsequently, the resident was transferred to an acute care hospital, where she was deemed stable for discharge. However, the facility refused to readmit her, resulting in the resident remaining at the hospital for five days. The facility did not provide the resident or her conservator with a 7-day bed hold notice or a 30-day discharge or transfer notice, as required by their policy. Interviews with the Director of Nursing (DON) and the Social Services Designee (SSD) revealed that the facility did not anticipate the resident's return and had not communicated the necessary notices. Despite having 12 empty beds, the facility did not re-evaluate the resident's ability to return, nor did they maintain adequate communication with the acute care hospital. The facility's policy on bed-hold and return to the facility, as well as their transfer and discharge notice policy, were not followed. The resident's conservator confirmed that the resident remained at the acute care hospital awaiting placement at another facility. The failure to adhere to these policies resulted in the resident being held at the hospital without proper notice or evaluation for return to the facility.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to ensure residents received dental services for two residents, Resident 166 and Resident 75. Resident 166 was admitted to the facility in September 2023 with multiple diagnoses, including disturbances of salivary secretions. Despite having missing teeth, cavities, and a loose tooth, Resident 166 had not been seen by a dentist since admission. Multiple staff members, including CNAs and LNs, confirmed the poor condition of Resident 166's teeth and the lack of dental records in his chart. The facility's process for scheduling dental appointments was not followed, and there was no record of any attempts to obtain dental services for Resident 166 within the first 90 days of admission, as required by the facility's policy. The DON and other staff members acknowledged the oversight and the potential health complications that could arise from not receiving timely dental care. Resident 75 also did not receive timely dental services. Despite having a dental care plan initiated in May 2015 and a dental note from September 2023 indicating the need for further dental treatment, Resident 75 had not seen a dentist for seven months. The Consultant Coordinator confirmed that the company performing dental care visited the facility monthly, but Resident 75's recommended dental treatment had not been scheduled. During an interview, Resident 75 reported tooth pain, and the facility's policy on dental services, which required licensed nursing staff to notify social services of a resident's need for dental services, was not followed. The facility's failure to provide dental services for Resident 166 and Resident 75 resulted in both residents not obtaining necessary dental care. This lack of action had the potential to cause health complications, including pain, infection, and difficulty eating. The facility's processes for scheduling and tracking dental appointments were not adequately followed, leading to these deficiencies in care.
Failure to Ensure Resident Dignity and Safety During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a CNA stood over the resident while assisting her with her lunch meal. During an observation and interview, the CNA admitted that she should have been sitting next to the resident to properly assist her with eating and to monitor for any potential choking hazards. The CNA acknowledged that she had forgotten to follow the correct procedure. The resident's care plan indicated that she required assistance with meals due to dementia, a left-hand contracture, and schizophrenia, which necessitated close supervision during meals. The Assistant Director of Staff and Development confirmed that staff should sit next to residents while assisting them with meals to ensure safety and create a home-like environment. A review of the facility's dining program policy also indicated that staff should sit while feeding residents and observe them for safety issues and functional difficulties. The policy emphasized the importance of creating a positive dining experience by smiling and providing words of encouragement to promote and increase food intake.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's needs were met when the call light was found on the floor and not within reach. This deficiency was observed during a concurrent observation and interview with a CNA, who acknowledged that the call light was not accessible to the resident. The resident, identified as having ataxia and a high fall risk, was dependent on staff for basic care and required the use of a wheelchair. The resident's clinical records indicated a high fall risk due to factors such as low blood pressure, unstable gait, and the use of medications that increased the risk for falls. The resident's care plan included interventions to anticipate and meet the resident's needs and encourage the use of the call light if assistance was needed. Further interviews with LN 1 and LN 2 confirmed that the call light should have been accessible to the resident at all times. The Director of Nursing and the Administrator both acknowledged that the facility's policy and procedure regarding call lights, which required the call light to be within reach of the resident upon leaving the room, was not followed. The failure to adhere to this policy could have resulted in the resident being unable to alert staff in case of an emergency or if assistance was needed.
Failure to Document Evaluation for Use of Lap Buddy
Penalty
Summary
The facility failed to ensure an evaluation or assessment was documented in the medical record for a resident when the use of a lap buddy was initiated after multiple falls. The resident was observed multiple times with the lap buddy secured across her lap, and staff confirmed its use every time she was in her wheelchair. The resident indicated that staff would secure the lap buddy back in place if she tried to remove it. Despite the use of the lap buddy, there was no documented initial evaluation or periodic assessments for its continued use in the resident's medical record. The resident's care plan and interdisciplinary team (IDT) notes indicated a history of falls and the use of the lap buddy for safety, but lacked documented evaluations or assessments for its use. Interviews with staff confirmed the absence of a medical diagnosis from a physician for the lap buddy and the lack of documented assessments. The facility's policy required regular nursing assessments, but these were not conducted for the lap buddy, leading to the deficiency in ensuring the resident was free from the use of physical restraints without proper medical evaluation and documentation.
Failure to Ensure Accurate Dental Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's dental condition, leading to a delay in dental care services. Resident 166, admitted in September 2023 with multiple diagnoses including disturbances of salivary secretions, reported not being seen by a dentist while in the facility. Observations revealed that Resident 166 had two missing teeth, a black and broken tooth, and a loose tooth, which he had informed the staff about, but no action was taken. The resident's admission note indicated missing teeth and cavities, but there was no record of a dental consultation being arranged within the first 90 days of admission. The MDS assessment for Resident 166 did not accurately reflect his dental condition, as it failed to document cavities or broken teeth. The MDS nurse confirmed that the assessment was inaccurate and acknowledged that proper documentation would have led to a referral for dental services. The inaccurate assessment resulted in Resident 166 not receiving necessary dental care, which could affect his ability to chew food and potentially lead to further dental issues. The Director of Nursing (DON) stated that nurses are expected to assess residents' dental health upon admission and refer them for dental consultations if needed. The DON emphasized the importance of accurate assessments for creating appropriate care plans. The facility's policy on the Minimum Data Set (MDS) requires comprehensive assessments, including dental status, to be completed accurately to ensure residents receive the necessary care. The failure to accurately assess and document Resident 166's dental condition led to a lack of timely dental care, which could result in health complications.
Failure to Provide Oral Hygiene Supplies and Care
Penalty
Summary
The facility failed to ensure necessary care and services were provided to Resident 166, who did not have oral hygiene supplies and did not receive oral hygiene from staff. Resident 166, admitted in September 2023 with multiple diagnoses including disturbances of salivary secretions, was observed to have poor oral hygiene, including missing and broken teeth, and buildup on his teeth. The resident reported difficulty chewing food and indicated that his teeth were not being properly cared for by the staff. Certified Nursing Assistants (CNAs) verified that Resident 166's teeth were in poor condition and needed cleaning. They also confirmed that the resident did not have a personal hygiene basket with oral care supplies in the utility room, which was supposed to be provided. Despite claims that the resident refused to brush his teeth, there was no documentation in the behavior monitoring log to support this. The CNAs admitted that they might have documented the oral hygiene tasks incorrectly in the electronic record. The Director of Nursing (DON) stated that staff were expected to provide oral hygiene to residents twice a day and document any refusals of care. The DON confirmed that residents' oral hygiene supplies were kept in labeled baskets in the utility room to prevent infection control issues. The facility's policy on oral care indicated that residents should receive adequate oral care to maintain dignity, comfort, and oral hygiene, which was not adhered to in the case of Resident 166.
Failure to Prevent Potential Accidents and Injuries
Penalty
Summary
The facility failed to ensure that two residents were free from potential accidents and injury. Resident 75 was observed lying in bed without the fall mat laid out on the floor as per the care plan. The fall mat was found folded up and positioned next to the nightstand. Licensed Nurse 4 confirmed that the fall mat was not implemented, which posed a risk of falls and injury. Resident 75's care plan indicated a high risk for falls due to various medical conditions and a history of multiple falls. The fall mat was added as an intervention to prevent injury from falls, but it was not in place during the observation. Resident 141's bed side rails were found in an unsafe position, with the right-side rail angled away from the bed and touching the floor. This positioning created a tripping hazard. Certified Nursing Assistant 1 and Licensed Nurse 1 both confirmed the unsafe positioning of the side rail and acknowledged the risk it posed for Resident 141, who had a high fall risk due to ataxia and other medical conditions. The Maintenance Director was not informed of the issue, and the Director of Nursing acknowledged that the facility's policies and procedures for side rails and safety were not followed. The facility's policies and procedures required regular checks for bed rail safety and prompt reporting of any environmental concerns. However, these protocols were not adhered to, leading to the unsafe conditions observed for both residents. The Administrator also confirmed that the policies were not followed, acknowledging the risk for injury due to the improper positioning of the bed side rail for Resident 141.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse by Resident 2, resulting in Resident 1 experiencing emotional distress and a physical injury. Resident 1, diagnosed with schizoaffective disorder, bipolar type, was punched in the nose by Resident 2, who has dementia with psychotic disturbance, during an altercation in their shared bathroom. The incident occurred when Resident 1 demanded that Resident 2 get off the toilet, leading to Resident 2 becoming upset and punching Resident 1, causing a nosebleed. Staff intervened, applied an ice pack to Resident 1's nose, and moved Resident 2 to a different room for safety. Resident 2 had a documented history of assaultive behavior, including previous incidents of yelling at others and spitting in a staff member's face. Despite this history, the facility did not adequately prevent the altercation between the two residents. The facility's policy on elder and dependent adult abuse emphasizes the right of residents to be free from physical abuse, yet this incident demonstrates a failure to uphold that policy. Interviews with staff and residents confirmed the details of the altercation and the emotional impact on Resident 1.
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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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