Desert Canyon Post Acute, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, California.
- Location
- 1642 West Avenue J, Lancaster, California 93534
- CMS Provider Number
- 055307
- Inspections on file
- 89
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Desert Canyon Post Acute, Llc during CMS and state inspections, most recent first.
A resident with Guillain-Barre Syndrome and hypertension was discharged to recuperative care without written confirmation of acceptance, resulting in the resident being denied by the receiving facility and subsequently left at a hospital. Facility staff confirmed that only verbal and email communications were obtained, and no official documentation of acceptance was present, contrary to facility policy requiring proper preparation and confirmation for safe discharge.
The facility failed to follow its infection prevention and control and reporting policies after bed bugs were discovered in a shared room occupied by three cognitively intact residents with multiple comorbidities and varying dependence on staff for ADLs. A CNA and an LVN observed insects on a resident’s bed, and the IP later confirmed that a pest management company identified bed bugs on one mattress. Despite acknowledging that bed bugs can be transferred via clothing and linens and can cause skin reactions, the IP reported that no contact tracing was initiated, no systematic assessment of other residents for bites or rashes was conducted, and no surveillance or monitoring system for bed bugs was developed. Facility leadership and policy documents characterized bed bugs as an unusual occurrence with potential impact on resident safety and health, yet the facility did not report this event to the Department of Public Health as required by its own outbreak and reportable disease policies.
The facility failed to revise comprehensive care plans for three cognitively intact residents sharing a room after bed bugs were discovered on one resident’s mattress. CNAs observed small red insects on the resident’s bed during personal care, and an LVN confirmed the presence of insects and completed a skin assessment that showed no bites at that time. A pest management company later confirmed bed bugs in the room and performed heat treatment. Despite this, the residents’ care plans were not updated to include monitoring for skin issues or other complications related to potential bed bug exposure, contrary to the facility’s policy requiring person-centered care plans that address medical, physical, mental, and psychosocial needs.
A resident with severe cognitive impairment and high fall risk was found with the call light on the floor and out of reach after ADL care was provided. Staff interviews confirmed that facility policy and the resident's care plan required the call light to be accessible, but this was not followed, resulting in a deficiency related to reasonable accommodation of resident needs.
Two residents were subjected to physical restraint practices without proper assessment or documentation. One resident's bed was placed against the wall without the required quarterly restraint assessments, and another had pillows tucked under the fitted sheet as a restraint, which was not ordered or care planned. These actions did not comply with facility policy and restricted the residents' freedom of movement.
Three residents were moved to new rooms without receiving written notice or an explanation for the change, as required by facility policy. One resident, who is blind, struggled to adapt to a smaller, less accessible room, while another felt disregarded after being moved without consultation or documentation. A third resident was relocated after complaining about a roommate, without being oriented to the new environment. The Social Service Director confirmed that no written notifications were provided to the residents or their representatives.
Three residents were moved to new rooms without receiving written notification or explanation as required by facility policy and regulatory guidance. One resident, who was blind and had diabetes, was not oriented to her new room and struggled with the new environment. Another resident, dependent on staff due to cerebral infarction, was moved without being consulted or given documentation. A third resident, who had a UTI and required substantial assistance, was relocated after complaining about a roommate, without orientation or choice. The facility's governing body did not ensure that policies were updated or followed.
A resident who needed substantial assistance with ADLs and had an intact thought process was not fully covered while walking in the hallway with a physical therapist student, resulting in exposure of the incontinence brief. The PT student and DON both acknowledged the importance of maintaining resident dignity by ensuring full coverage, as required by facility policy.
A Hoyer lift was found parked in front of an emergency exit, with an emergency crash cart and two wheelchairs also obstructing the hallway. An LVN and the DON confirmed that these items were improperly placed, blocking exits and hallways, contrary to facility policy requiring a safe and accessible environment.
A resident with muscle weakness and paraplegia experienced an unwitnessed fall, but the subsequent Fall Risk Evaluation inaccurately recorded a lower risk score. The nurse failed to document the fall, note the need for assistive devices, and incorrectly indicated no falls in the last three months, leading to a deficiency in the facility's documentation practices.
Two residents in an LTC facility engaged in a verbal altercation, exchanging derogatory words, which was witnessed by staff members. Despite facility policies on abuse prevention, the incident was considered verbal abuse, highlighting a failure to protect residents from mistreatment. Both residents had cognitive impairments and required assistance with daily activities.
The facility employed an Activity Director (AD) who did not meet the qualifications outlined in the job description. The AD, hired in October 2024, lacked the required certification in long-term care specialization and did not maintain written records of residents' attendance at activities. The DON and ADM confirmed the AD's hiring and training, but the ADM admitted the AD was likely not qualified according to the job description.
A resident with sepsis, diabetes, and end-stage renal disease refused multiple medications over several days, but the facility failed to develop a care plan to address this. Despite the resident's capacity to make decisions, the facility did not create a care plan after the resident refused medication three times, as required by policy. The DON acknowledged the oversight during a review.
A facility failed to provide a resident-centered activity program for a resident with dementia and other health issues. The resident was not assessed for activities upon admission, and there was no documentation of activity participation. Interviews revealed miscommunication and lack of documentation, contrary to the facility's policy requiring assessment of residents' interests and preferences.
A resident with cognitive capacity and specific activity preferences was not offered a resident-centered activity program, as required by the facility's policy. Despite the resident's ability to make decisions, there was no documented activity attendance, and the resident expressed that they were not asked about their daily preferences. Interviews revealed a lack of implementation of a personalized activity plan.
A facility failed to implement infection control measures for a resident on enhanced barrier precautions (EBP). A nurse did not wear a protective gown while providing wound care, despite the resident having a diabetic foot ulcer and a dialysis port. The facility's policy required gown use during high-contact care activities for residents with wounds or indwelling devices. Observations and interviews confirmed the nurse's non-compliance with EBP requirements.
The facility's nursing staff failed to rotate insulin injection sites for three residents, leading to potential risks of tissue damage and ineffective medication absorption. Despite physician orders and facility policy requiring site rotation, insulin was repeatedly administered in the same areas, such as the arms and abdomen. This non-compliance was confirmed by the ADON, highlighting a significant lapse in adhering to professional standards of care.
The facility failed to implement necessary fall prevention and hazard mitigation measures for three residents. A resident with a history of falls did not have ordered landing mats, another high-risk resident lacked a wheelchair pad alarm, and a third resident had a bed remote with frayed wires, posing an electrical hazard. These oversights were confirmed by staff and acknowledged by the DON, indicating a breach in the facility's safety protocols.
The facility failed to conduct complete assessments for the use of bed rails for three residents, leading to potential risks of injury. Despite having signed consents for bed rails as mobility enablers, the assessments lacked necessary recommendations and considerations for entrapment risks. The DON and ADON acknowledged the incomplete assessments, which could result in improper intervention initiation and potential resident harm.
The facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite physician orders and facility policy requiring site rotation to prevent tissue damage, insulin was repeatedly administered in the same areas. This was confirmed by the ADON and DON, who acknowledged the practice as a medication error.
A LTC facility failed to maintain an effective infection prevention and control program. A TN did not perform hand hygiene between glove changes during wound care, contrary to facility policy. Two residents' nasal cannulas were not labeled with the date last changed, risking respiratory infections. An LVN did not implement Enhanced Barrier Precautions during medication administration for a resident with a gastrostomy tube, failing to don a gown as required.
A resident with cerebral infarction, vascular dementia, and pneumonia was found with a bruise on her forehead and an inaccessible call light, which was wrapped around the bed's side rail. The CNA confirmed the call light should have been within reach, as per facility policy, to allow the resident to summon assistance. The DON acknowledged the deficiency, which could lead to delayed care.
A resident with type 2 diabetes and gastrostomy status was administered the wrong enteral feeding formula, Fibersource HN, instead of the prescribed Diabetisource AC. This error was confirmed by a registered nurse and the Assistant Director of Nursing, who noted that the licensed nurse failed to verify the formula against the physician's order, as required by the facility's policy. This oversight risked complications for the resident.
A facility failed to store a resident's nebulizer mask and tubing in a labeled plastic bag, as required by their policy, potentially risking respiratory infections. The resident had a history of stroke, dysphagia, and COVID-19. The LVN and ADON confirmed the importance of proper storage to prevent infection, but the equipment was found improperly stored during an observation.
A facility failed to ensure safe handling and storage of medications for a resident. A bubble pack containing midodrine had a broken seal and was covered with paper tape, indicating tampering. The LVN confirmed the medication should have been discarded once removed from the pack. The ADON and DON stated the medication should have been discarded if dispensed without checking the resident's BP. Facility policies required immediate disposal of contaminated medications.
The facility failed to monitor and manage psychotropic medications for two residents. One resident's sleep was not documented as required for Trazodone use, and another resident's pimavanserin order lacked specific behavior monitoring and diagnosis. The ADON acknowledged these deficiencies, which contravened the facility's policy on psychoactive medications.
The facility failed to label an open bottle of glucose test strips with the date it was opened, as required by the manufacturer's instructions. This oversight was discovered during an inspection of a medication cart, where an LVN was unable to provide the opening date. The ADON confirmed the requirement to label the date to ensure the strips are used within 90 days, as per the manufacturer's instructions and facility policy. This deficiency had the potential to result in inaccurate blood glucose readings, affecting insulin dosage for residents.
A facility failed to adhere to a resident's dietary preferences and needs by serving regular milk, which was listed as a dislike, to a resident on a renal diet. The resident, who had end-stage renal disease, was also not provided with the correct meal portions as ordered. Staff interviews revealed a lack of awareness and adherence to the resident's dietary preferences, contributing to the oversight.
A resident with end-stage renal disease and other conditions was not served meals according to the physician's diet order, which included a consistent carbohydrate, liberal renal diet with double portions. Instead, the resident received a single portion and regular milk, which was listed as a dislike and inappropriate for their renal diet. The Dietary Supervisor confirmed the meal did not meet the prescribed requirements, and the Assistant Director of Nursing admitted to not knowing where to check the resident's food preferences, leading to the oversight.
The facility failed to maintain safe food storage and preparation practices, with a tomato found on the floor of the walk-in refrigerator, lack of separate thermometer probes in freezers, and improperly labeled and stored food items. Additionally, wet drink pitchers were stacked improperly, risking cross-contamination. The Dietary Supervisor, Director of Nursing, and Registered Dietitian acknowledged these issues, which were contrary to the facility's policies and the Food Code 2022.
The facility failed to ensure accurate assessments for three residents, leading to potential delays in necessary care. One resident's MDS did not reflect hospice services, another's did not indicate a feeding tube, and a third's omitted a fall incident. These inaccuracies were confirmed by the MDS Coordinator and DON, highlighting the need for precise documentation to inform care planning.
Two residents in an LTC facility were involved in a verbal altercation where one resident used profanity and derogatory language towards the other. Despite the incident occurring during an activity session, the Activities Director did not document or report it immediately, leading to a delay in separating the residents. Both residents had care plans developed after the incident, but the delay in reporting and action posed a risk for further abuse.
A facility failed to report an alleged verbal abuse incident between two residents within the required timeframe. One resident verbally abused another during an activity session, but the Activities Director did not report the incident immediately, contrary to the facility's policy. The delay in reporting and lack of immediate intervention placed both residents at risk for further abuse.
A resident's cell phone was taken by another resident, leaving the affected individual unable to contact family. Despite initiating an abuse protocol, the facility did not replace the phone, and the resident's family had to order a new one. The incident highlights a failure to protect personal property as per facility policies.
A resident in an LTC facility experienced physical abuse when another resident poured lemon juice on their face, causing eye irritation. The affected resident, who had mobility and mental health issues, felt defenseless and was unable to sleep. The facility failed to report the incident's impact to nursing staff or provide timely psychological evaluations, despite policies emphasizing resident protection and dignity.
A resident with chronic obstructive pulmonary disease, muscle weakness, and essential hypertension, identified as a high fall risk, was left unsupervised in a Geri-chair, leading to a fall and multiple fractures. The facility failed to update the care plan with necessary interventions and did not follow its fall management policies, resulting in inadequate supervision and care.
The facility failed to maintain complete and accurate documentation for two residents. One resident's altercation date and refusal of psychological evaluations were not properly recorded, while another resident's EMS notification and hospital transfer times were missing. Additionally, incorrect dates were noted for notifying the physician and family. These documentation errors were acknowledged by staff and contradicted facility policies.
The facility failed to monitor daily temperatures for several days, compromising the safety and comfort of residents during extreme heat conditions. Portable AC units were used in residents' rooms, and the Maintenance Director could not provide evidence of temperature checks. The Director of Nursing was unaware of any AC issues, despite the facility being under a heat advisory.
A resident with COPD, major depressive disorder, and anxiety disorder experienced verbal abuse from a Kitchen Coordinator (KC) who yelled at them to shut up during a dispute over a diet slip. The resident, who felt humiliated and unsafe, was in a wheelchair and required oxygen. The incident was witnessed by staff, and the KC was found to lack a background check. The facility's policies on abuse prevention and resident rights were not upheld, leading to a deficiency in protecting the resident's safety and dignity.
A resident with cirrhosis, ascites, and hypertension refused lactulose medication and showers multiple times without a comprehensive care plan being developed. The facility staff did not notify the doctor or document the refusals as required by policy.
The facility failed to implement infection control measures for a resident on enhanced barrier precautions due to a gastrostomy tube. CNA 1 did not wear a protective gown during care, and LVN 1 was not informed of the resident's status. The lack of communication and proper reporting between shifts contributed to the failure in infection control.
A facility failed to notify a resident's POA about an abrasion on the resident's coccyx. Despite attempts to contact the POA, the facility did not follow up adequately, leading to the POA discovering the wound during a doctor's appointment. This failure violated the resident's rights to be fully informed and to have their representative involved in care decisions.
Failure to Confirm Acceptance Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for a resident diagnosed with Guillain-Barre Syndrome and hypertension, who required partial assistance with activities of daily living and had no cognitive impairment. The resident was initially admitted and later readmitted to the facility, with discharge planning indicating a return to recuperative care upon discharge. However, the facility discharged the resident to recuperative care without obtaining written confirmation that the receiving facility would accept the resident. On the day of discharge, the resident left the facility with all medications and belongings, but shortly after, the outside social service worker (OSSW) notified the facility that recuperative care would not accept the resident due to their medical condition. The resident returned to the facility parking lot and requested assistance, after which the assistant social worker (ASSW) accompanied the resident to a hospital and left the resident in the hospital parking lot. The resident then walked into the emergency room independently. Interviews with facility staff, including the ASSW, social service worker, administrator, and director of nursing, confirmed that there was no written or official confirmation from recuperative care regarding acceptance of the resident. The facility relied on verbal and email communication from the OSSW and did not have documentation of acceptance. Facility policy required sufficient preparation and orientation to ensure safe and orderly transfer or discharge, which was not followed in this instance.
Failure to Implement Bed Bug Surveillance and Reporting Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program and related policies when bed bugs were identified in a shared resident room. On 10/9/2025, a CNA assisting a resident in Room A around 4 a.m. observed several small red insects on the white linen covering the resident’s mattress and notified another CNA, who then informed an LVN. The LVN went to Room A, confirmed the presence of small insects on the resident’s bed, notified an RN, and completed a skin assessment that did not show signs of bed bug bites. The Infection Preventionist (IP) was later informed by a supervisor that a bed bug had been seen in Room A and went to assess the residents in that room, again not observing signs of bed bug bites. Resident records showed that three cognitively intact residents with varying levels of dependence for activities of daily living were residing in Room A. One resident had diagnoses including type 2 diabetes mellitus, cerebral infarction, and cardiomegaly and was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. A second resident had type 2 diabetes mellitus, osteomyelitis, and muscle weakness, required supervision for toileting and personal hygiene, and needed assistance for showers, dressing, and ambulation. A third resident had a history of cerebrovascular accident with right-sided hemiplegia, end-stage renal disease, and dependence on dialysis, and required moderate to maximal assistance with hygiene and dressing but was independent in wheelchair mobility. A pest management company inspected Room A later that morning and positively identified bed bugs on one mattress, with a recommendation for heat treatment. The IP stated that bed bugs can be transferred via clothing and linens and can cause bites, allergic reactions, rash, itchiness, and welts, but acknowledged that the facility did not initiate contact tracing between residents in Room A and staff assigned to that room, nor between those staff and other residents. The IP further stated that residents outside Room A were not assessed for bed bug bites or skin rashes, and that the facility failed to develop a surveillance and monitoring system for bed bugs after the incident. The Maintenance Supervisor confirmed that the pest control company conducts monthly inspections and that the 10/9/2025 bed bug finding was not a usual occurrence. The Administrator and Assistant Director of Nursing both indicated that bed bugs were not a usual occurrence in the facility and that failure to thoroughly inspect the facility and residents for bed bugs had the potential to affect resident safety. Review of facility policies showed that the Infection Prevention and Control Program policy required the facility to identify, investigate, control, and prevent infections and to maintain a safe, sanitary, and comfortable environment. A separate Bed Bugs policy stated its purpose was to ensure the facility takes precautions needed to prevent, control, and manage a bed bug infestation. The facility’s Reportable Diseases and Communicable Diseases–Outbreak policies defined “unusual occurrences” as events such as epidemic outbreaks or other occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors, and indicated that such occurrences should be promptly identified and reported. The Administrator stated that bed bugs were not a usual occurrence in the facility and that their identification had the potential to negatively affect resident safety and health, but the facility did not contact the Department of Public Health to report this unusual occurrence, contrary to its policies.
Failure to Revise Care Plans After Bed Bug Infestation in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to review and revise the comprehensive care plans for three cognitively intact residents sharing the same room after bed bugs were identified on one resident’s mattress. Resident 1, originally admitted in 2022 and readmitted in 2025 with diagnoses including DM II, cerebral infarction, and cardiomegaly, was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. Resident 2, admitted in July 2025 with DM II, osteomyelitis, and muscle weakness, required supervision or moderate assistance for hygiene and dressing. Resident 3, admitted in February 2025 with CVA, right-sided hemiplegia, end stage renal disease, and dependence on dialysis, required moderate to maximal assistance with hygiene and dressing. All three residents had documented capacity to make decisions and intact cognitive functioning. On the early morning of 10/9/2025, CNA 1, while assisting Resident 1 with perineal care, observed several small red insects on the white linen covering Resident 1’s mattress near the resident’s head. CNA 2 informed LVN 1, who then went to the room between 4 a.m. and 5 a.m. and also observed small insects on Resident 1’s bed. LVN 1 notified an RN and completed a skin assessment on Resident 1, noting no signs of bed bug bites such as red bumps or rash at that time. The room, shared by Residents 1, 2, and 3, was subsequently inspected by a pest management company, which confirmed bed bugs on one mattress and recommended heat treatment. Service notifications from the pest management company documented a positive identification of bed bugs in Room A on 10/9/2025 and completion of heat treatment on 10/10/2025. Despite these findings and the shared occupancy of the room by three residents, the facility did not revise or update the comprehensive care plans for Residents 1, 2, and 3 to address monitoring for skin problems or other complications related to potential bed bug bites. In an interview, the ADON acknowledged that the care plans were not revised after the bed bugs were found and stated that the care plans should have been updated with interventions for staff to monitor for skin problems and report issues to the physician. The facility’s own policy on developing and implementing comprehensive, person-centered care plans requires addressing each resident’s medical, physical, mental, and psychosocial needs.
Call Light Not Placed Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for a resident with significant cognitive impairment and high fall risk. The resident, who had diagnoses including sepsis, schizoaffective disorder bipolar type, dementia, and major depressive disorder, was unable to make decisions or communicate needs effectively. The resident required substantial to total assistance with activities of daily living and was assessed as high risk for falls. The care plan specifically directed staff to keep the call light within easy reach and encourage its use to minimize fall risk. During an observation, the resident was found asleep in bed with the call light on the floor at the foot of the bed, out of reach. A CNA acknowledged that after providing ADL care, she should have ensured the call light was within reach, as required by facility policy and the resident's care plan. Both the ADON and DON confirmed that staff are expected to place call lights within reach after care, and failure to do so could result in unmet needs and increased risk for the resident. The facility's policy also stated that the call system must be accessible to residents while in bed.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by the care of two residents. For one resident with schizoaffective disorder, major depressive disorder, and seizures, the facility placed the bed against the wall as a fall prevention measure. Although there was a physician's order for this intervention, the facility did not complete the required quarterly restraint assessments to evaluate the continued appropriateness of this measure, as mandated by facility policy and the resident's care plan. The only documented restraint assessment was from several months prior, and both the Assistant Director of Nursing and the Director of Nursing confirmed that quarterly assessments were not performed as required. Another resident, diagnosed with sepsis, schizoaffective disorder, dementia, and major depressive disorder, was found with pillows tucked under the fitted sheet on one side of the bed, with the bed itself against the wall on the other side. This intervention was implemented by a CNA to prevent falls, but there was no physician's order or care plan documentation supporting this practice. The CNA stated that they believed this was not a restraint, but facility policy and the ADON clarified that tucking pillows under the fitted sheet is considered a restraint and is not permitted, as it restricts the resident's freedom of movement. Both cases demonstrated a lack of adherence to the facility's own policies and procedures regarding the use of physical restraints. The required interdisciplinary team discussions, documentation, and ongoing evaluations were not completed for the use of the bed against the wall, and unauthorized restraint practices were implemented without proper assessment or documentation for the use of pillows under the fitted sheet. These actions resulted in the restriction of residents' freedom of movement and did not honor their right to be free from physical restraints.
Failure to Provide Written Notice and Orientation for Room Changes
Penalty
Summary
The facility failed to provide written notice indicating the reason for room changes for three residents, as required by its own policy and federal regulations. Each resident was moved to a different room without receiving written documentation explaining the reason for the change. Interviews revealed that one resident, who is blind and had been in her previous room for over a year, was moved to a smaller room at the far end of the building, which made it difficult for her to navigate and caused her distress. Another resident reported being moved without being asked or given any documentation, leading her to feel disregarded and unable to exercise her right to make decisions about her living arrangements. A third resident, after complaining about a noisy roommate, was told she had to move because she was the complainant, and was not oriented to her new room or roommate. Review of facility policy confirmed that written notice, including the reason for the room change, should be provided to residents, and that social services staff are responsible for assisting with orientation to the new room and roommate. The Social Service Director acknowledged that no written notifications were given to the affected residents or their responsible parties. The lack of written notice and orientation resulted in the residents feeling their rights were violated and left them feeling upset and disempowered.
Failure to Provide Written Notification and Explanation for Room Changes
Penalty
Summary
The facility failed to update and implement its policy and procedure regarding room changes, affecting three residents who were moved without proper written notification or explanation. The facility's current policy required written notice for room or roommate changes, including the reason for the move, but this was not followed in practice. The Social Service Director confirmed that no written notifications were provided to the residents or their responsible parties, and the Director of Nursing acknowledged that the policy did not align with regulatory guidance requiring written explanations for such moves. Resident 1, who was blind and had type 2 diabetes mellitus, was moved from her room of over a year to a new location designated for isolation purposes. She reported not being oriented to the new room, experiencing difficulty navigating the space, and feeling that her needs were disregarded due to the room's location and size. Resident 2, with a diagnosis of cerebral infarction and dependent on staff for activities of daily living, stated that staff moved her without asking for her input or providing any documentation or explanation for the change, leaving her feeling disrespected and unable to exercise her rights. Resident 3, who had a urinary tract infection and required substantial assistance, was moved after complaining about a noisy roommate. She reported that staff informed her that the complainant would be the one moved, and she was not oriented to her new room or roommate. She felt forced to move and believed the process was unfair. The facility's governing body was found to be responsible for ensuring policies were updated and implemented, but failed to do so in accordance with regulatory requirements.
Resident's Dignity Compromised Due to Inadequate Coverage During Hallway Walk
Penalty
Summary
A deficiency occurred when a resident, who required substantial assistance with activities of daily living and had an intact thought process, was not fully covered while walking in the hallway with a physical therapist student. During the walk, the resident's gown was pulled upward, exposing the incontinence brief. The physical therapist student acknowledged that the resident's brief was exposed and stated the importance of keeping the resident covered to maintain dignity and comfort. The Director of Nursing confirmed that staff are required to ensure residents are fully covered at all times in public areas to protect their dignity. Facility policy on dignity and respect, reviewed on 10/30/2024, also states that residents must be treated with dignity and respect at all times, including assistance in maintaining self-esteem and self-worth. The failure to keep the resident covered in the hallway constituted a lack of dignity and respect as required by facility policy.
Obstructed Emergency Exit and Hallway by Equipment
Penalty
Summary
Surveyors observed that a Hoyer lift was parked directly in front of and close to an emergency exit door, an emergency crash cart was parked beside the utility room, and two wheelchairs were parked along the right side of the hallway in Station A. During the tour, a Licensed Vocational Nurse confirmed that these items were blocking the hallways and the exit door, acknowledging that such placement was inappropriate. The Director of Nursing also stated that emergency exits should not be blocked, as this could prevent residents from exiting during an emergency. Review of the facility's policy indicated that the environment should be safe, clean, comfortable, and not pose a safety risk, with the physical layout maximizing resident independence.
Inaccurate Fall Risk Assessment Documentation
Penalty
Summary
The facility failed to accurately document a Fall Risk Assessment for a resident after the resident experienced a fall. The resident, who was admitted with diagnoses including muscle weakness, difficulty in walking, and paraplegia, was identified as being at risk for falls due to gait and balance problems. Despite this, after an unwitnessed fall where the resident was found on the floor, the subsequent Fall Risk Evaluation inaccurately recorded a lower fall risk score. This was due to the nurse not marking the fall, not noting the need for assistive devices, and incorrectly indicating that the resident had not fallen in the last three months. The Director of Nursing acknowledged that the Fall Risk Evaluation was inaccurately documented, which could affect the nursing interventions provided to the resident. The facility's policy requires that fall risk assessments incorporate information from various sources, including the Minimum Data Set and Care Area Assessments, to ensure accurate and reliable evaluations. However, the failure to document the fall and update the risk assessment accordingly represents a deficiency in the facility's adherence to its own policies and procedures.
Verbal Altercation Between Residents Leads to Abuse Deficiency
Penalty
Summary
The facility failed to protect two residents from verbal abuse, which occurred when both residents engaged in a verbal altercation. Resident 2, admitted with diagnoses including muscle weakness, hypertension, and end-stage renal disease, had intact cognitive skills for daily decision-making but required assistance with various activities of daily living. Resident 3, admitted with major depressive disorder, anxiety disorder, and hypertension, had moderately impaired cognitive skills and also required assistance with daily activities. On the day of the incident, Resident 2 and Resident 3 exchanged derogatory words in the activity room after a male resident called Resident 2 over to his table, where Resident 3 was sitting. The incident was witnessed by several staff members, including the Infection Preventionist, Activities Assistant, and Social Services Director, who all confirmed the verbal exchange between the two residents. The staff members described the situation as verbal abuse, noting that the derogatory language used could lead to emotional and mental distress for the residents involved. The Director of Nursing, although not present during the incident, also acknowledged that such behavior constitutes verbal abuse and should not occur among residents. The facility's policies and procedures on abuse prevention and prohibition were reviewed, indicating that each resident has the right to be free from mistreatment and neglect. Despite these policies, the incident highlights a failure in the facility's responsibility to maintain an environment free from abuse, as both residents were subjected to verbal abuse while under the facility's care.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified Activity Director (AD) who met the qualifications as per the facility's job description. During interviews and record reviews, it was revealed that the AD, hired in October 2024, did not maintain a written record of residents' attendance at activities and lacked the required certification in long-term care specialization. The Director of Nursing (DON) and the Administrator (ADM) confirmed that the AD was hired by the ADM and received training and orientation upon hiring. However, the ADM acknowledged that the AD was probably not qualified based on the facility's job description, which required a current Activities Director certification in long-term care specialization.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who refused medication, which was identified during a survey. The resident, admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease, had the capacity to understand and make decisions. Despite this, the resident refused multiple medications over several days in January 2025, including those for high blood pressure, cholesterol, depression, and other conditions. The Medication Administration Record documented these refusals, but no care plan was created to address the medication refusal. During an interview and record review, the Director of Nursing acknowledged the absence of a care plan for the resident's medication refusal. The facility's policy required a care plan to be created after a resident refused medication three times, but this was not done. The policy also emphasized the importance of a person-centered, comprehensive care plan developed by the interdisciplinary team, including the resident's participation. The lack of a care plan for the resident's medication refusal was identified as a deficient practice with the potential for delayed provision of necessary care and services.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program for a resident who was admitted with diagnoses including an unspecified fracture of the right patellar, unspecified dementia, and a history of falls. Upon review, it was found that the resident's cognitive skills for daily decisions were severely impaired, and they were dependent on staff for toileting and showering. Despite these needs, the resident had not been assessed for activities, and there was no documented activity participation or attendance since their admission. Interviews with the Director of Nursing (DON) and the Activity Director (AD) revealed a lack of communication and documentation regarding the resident's activity assessment and participation. The DON acknowledged that the resident should have been assessed within three days of admission, and the AD admitted to a miscommunication about the necessary steps to complete the assessment. The facility's policy requires that residents be assessed upon admission to identify their interests and preferences, but this was not done for the resident in question, leading to a deficiency in meeting their psychosocial needs.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide a resident-centered ongoing activity program for a resident, which had the potential to affect the resident's sense of self-worth and psychosocial well-being. The resident was admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease. Despite having the cognitive capacity to understand and make decisions, the resident was not offered activities that aligned with their preferences, such as movies, outdoor time, eating snacks, and playing with their phone. The resident expressed that they were not asked about their daily activity preferences. Interviews with the Activity Director and the Director of Nursing revealed that the resident preferred staying in their room and did not like sitting on a chair for long periods. However, there was no documented activity attendance for the resident in November and December. The facility's policy stated that an ongoing activities program should support residents' physical, mental, and psychosocial well-being, but the activity staff failed to document or implement a resident-centered activity plan for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection control measures for a resident who was on enhanced barrier precautions (EBP). Treatment Nurse 1 (TN 1) did not wear a protective gown while providing wound care to the resident, who had a diabetic foot ulcer and a dialysis port. The resident was admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices, even if they were not known to be infected with multidrug-resistant organisms. During observations and interviews, it was noted that TN 1 exited the resident's room wearing gloves and a mask but without a protective gown, despite the EBP signage indicating the requirement for gown use. The Admissions Director, Director of Staff Development, and Director of Nursing all confirmed that the protective gown should have been worn to prevent the transmission of infection. The facility's policy on EBP, dated April 2024, outlined the necessity of using personal protective equipment during care activities that could transfer multidrug-resistant organisms to staff hands and clothing.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for three residents, leading to a potential risk of adverse effects. Resident 21, who was admitted with type 2 diabetes, paraplegia, and other conditions, received insulin injections repeatedly in the same areas, particularly the right lower quadrant of the abdomen and the right arm. This practice was contrary to the physician's orders and the facility's policy, which required site rotation to prevent tissue damage and ensure effective medication absorption. Similarly, Resident 43, who had diagnoses including type 2 diabetes and generalized muscle weakness, also received insulin injections without proper site rotation. The Medication Administration Record (MAR) showed repeated use of the same injection sites, such as the left arm and right arm, over several months. The Assistant Director of Nursing (ADON) confirmed that the insulin administration sites were not rotated as per the physician's orders, which could lead to tissue injury and affect the medication's absorption. Resident 28, with a history of type 2 diabetes and hemiplegia, also experienced the same issue of non-rotated insulin administration sites. The MAR indicated repeated injections in the right arm, which was not in compliance with the physician's orders or the facility's policy. The ADON acknowledged the failure to rotate injection sites, which could result in lipodystrophy and other skin tissue damage. The facility's policy and the manufacturer's guidelines both emphasized the importance of rotating injection sites to minimize the risk of skin damage.
Failure to Implement Fall Prevention and Hazard Mitigation Measures
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards for three residents. Resident 45, who had a recent history of falls, did not have bilateral landing mats placed at the bedside as ordered by the physician. Despite being identified as high risk for falls, the landing mats were not in place, which was confirmed by both the Licensed Vocational Nurse and the Certified Nursing Assistant. The Director of Nursing acknowledged that the facility's policy and procedures on fall prevention were not followed, as the mats were not implemented to minimize the risk of injury. Resident 42, who was at high risk for falls due to impaired cognition and muscle weakness, did not have a pad alarm placed on the wheelchair as required. The absence of the alarm was noted during an observation when the resident attempted to get up unassisted. Both CNAs involved acknowledged the oversight, and the Director of Nursing confirmed that the pad alarm should have been in place to prevent falls, as per the facility's policy. Resident 60 was found to have a bed remote control with frayed wires, posing a risk of electrical shock. The CNA responsible for the resident's care identified the hazard and reported it to the Maintenance Supervisor. The Assistant Director of Nursing confirmed that all staff are responsible for reporting potential hazards, and the facility's policy requires maintaining equipment in safe operating condition. The presence of frayed wires was a clear violation of the facility's policy to provide a safe environment.
Incomplete Bed Rail Assessments Pose Risks to Residents
Penalty
Summary
The facility failed to ensure that residents were completely assessed for the use of bed rails, which led to deficiencies in the care of three residents. Resident 22, who was admitted with diagnoses including generalized muscle weakness, had a Bed/Side Rail Entrapment Risk Assessment that did not indicate recommendations for the use of bed or side rails. Despite having a consent form signed for the use of bed rails as a mobility enabler, the assessment was incomplete, and the Director of Nursing (DON) confirmed that the recommendations should have been indicated. This lack of a complete assessment posed a risk of improper intervention initiation. Similarly, Resident 184, who was admitted with legal blindness and generalized muscle weakness, also had an incomplete Bed/Side Rail Entrapment Risk Assessment. The assessment failed to indicate recommendations for the use of bed or side rails, despite the resident's representative having signed a consent form for their use as a mobility enabler. The DON acknowledged that the least restrictive measures and recommendations were not completed, which could lead to improper intervention initiation. Resident 44, diagnosed with hemiplegia and cerebral infarction, had an order for grab bars for bed mobility. However, the Bed/Side Rail Entrapment Risk Assessment did not include reasons and recommendations for their use. The Assistant Director of Nursing (ADON) confirmed that the assessment was incomplete and emphasized the importance of assessing for entrapment or strangulation risks. The failure to assess the need and risk of entrapment for the use of grab bars/side rails could potentially lead to injury, such as strangulation or entrapment.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For Resident 21, the facility did not rotate the subcutaneous insulin administration sites as required by the physician's orders and the facility's policy. The resident, who had diagnoses including type 2 diabetes and paraplegia, received insulin injections repeatedly in the same areas, such as the right lower quadrant of the abdomen and the right arm, over several months. This practice was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews, who acknowledged that not rotating the sites is a medication error. Similarly, Resident 43, who had diagnoses including type 2 diabetes and gastrostomy status, also experienced non-rotation of insulin administration sites. The Medication Administration Record (MAR) showed repeated injections in the same areas, such as the left and right arms, over a period of three months. The ADON and DON confirmed that the insulin administration sites were not rotated as per the physician's orders and the facility's policy, which is considered a medication error. Resident 28, with diagnoses including type 2 diabetes and hemiplegia, also received insulin injections without proper site rotation. The MAR indicated repeated injections in the right arm over several months. The ADON and DON verified that the insulin administration sites were not rotated according to the physician's orders and the facility's policy, constituting a medication error. The facility's policy and the manufacturer's guidelines both emphasize the importance of rotating injection sites to prevent tissue damage and ensure effective medication absorption.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Treatment Nurse (TN) who did not perform hand hygiene after removing used disposable gloves and before donning new ones while providing wound care to a resident with a stage 4 pressure ulcer. The TN mistakenly believed that hand hygiene was not necessary between glove changes if the resident had only one wound. This oversight was contrary to the facility's policy, which mandates hand hygiene between glove changes to prevent cross-contamination. Another deficiency was observed in the respiratory care area, where nasal cannulas (NC) for two residents were not labeled with the date they were last changed. This lack of labeling could lead to the NCs not being changed weekly as required, increasing the risk of respiratory infections. The facility's policy requires NCs to be changed weekly and labeled with the date to ensure compliance. However, staff failed to adhere to this policy, as evidenced by the unlabeled NCs and the uncertainty among staff about when the NCs were last changed. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube during medication administration. A Licensed Vocational Nurse (LVN) failed to don a gown while administering medications and enteral feeding, despite the presence of an EBP sign at the resident's room entrance. The facility's policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling devices to prevent infections. The LVN acknowledged forgetting to wear a gown, which was a deviation from the facility's infection control procedures.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, which is a necessary accommodation for their needs and preferences. The resident, who was admitted with diagnoses including cerebral infarction, vascular dementia, and pneumonia, was found lying in bed with a large bruise on her forehead and was unaware of how it occurred. The resident also did not know if she had a call light, which was observed to be wrapped around the bed's side rail and dangling towards the floor, making it inaccessible. A Certified Nursing Assistant (CNA) confirmed that the call light was not within reach and should have been attached to the resident's sheet or blanket using a clasp, which was not utilized. The Director of Nursing (DON) reviewed the facility's policy, which mandates that call lights be accessible to residents to notify staff when assistance is needed. The failure to ensure the call light was within reach could result in a delay of care, as residents would be unable to summon help.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received the correct formula as per the physician's order. Resident 43, who was admitted with diagnoses including type 2 diabetes mellitus and gastrostomy status, was observed receiving Fibersource HN instead of the prescribed Diabetisource AC. This error was identified during an observation and confirmed by a registered nurse, who acknowledged that the licensed nurse did not follow the physician's order, which required checking the type of formula and infusion rate before administration. The Assistant Director of Nursing confirmed that the night shift licensed nurse hung the incorrect formula, which was not in accordance with the physician's order. The facility's policy and procedure for enteral feeding, last reviewed on 10/30/2024, mandates that the nurse verify the enteral nutrition label against the order before administration. This oversight placed Resident 43 at risk for increased blood sugar and gastrointestinal complications, as the incorrect formula was not suitable for their medical condition.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure that respiratory care provided to residents was consistent with professional standards of practice. Specifically, for one resident, the nebulizer mask and tubing were not stored in a plastic bag labeled with the resident's name and the date it was provided. This oversight was observed during a visit to the resident's room, where the Licensed Vocational Nurse (LVN) confirmed that the mask and tubing should have been stored properly to prevent bacterial or viral growth, which could lead to respiratory infections. The resident involved had a history of cerebral infarction, dysphagia, and a personal history of COVID-19. The facility's policy and procedure for nebulizer therapy required that equipment be stored in a labeled plastic bag between uses and discarded every seven days. The Assistant Director of Nursing (ADON) also confirmed that proper storage was necessary to prevent infection and cross-contamination among residents. The facility's infection prevention and control program aimed to maintain a safe environment and prevent disease transmission, but the failure to adhere to these procedures resulted in a deficiency.
Medication Handling and Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe handling and secure storage of medications for one of the sampled residents. During an inspection of a medication cart, it was observed that a bubble pack containing midodrine, a medication used to treat low blood pressure, had a broken seal and was covered with paper tape. The Licensed Vocational Nurse (LVN) confirmed that the medication slots with numbers 10 to 16 had been tampered with and should have been discarded once removed from the bubble pack. The LVN acknowledged that the medication could have been contaminated and that it was not possible to verify if the correct medication was placed back in the bubble pack. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that the medication should have been discarded if it was dispensed without checking the resident's blood pressure, as per the physician's parameters. The facility's policy and procedure on medication storage and labeling clearly stated that medications should not be returned to their original containers once removed, and any contaminated or improperly labeled medications should be immediately disposed of. The failure to adhere to these procedures resulted in a potential risk of medication error and contamination.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and manage the medication regimen for two residents, leading to potential unnecessary use of psychotropic drugs. For Resident 67, the facility did not document the number of hours the resident slept on two consecutive nights, despite an order to monitor sleep in relation to the use of Trazodone, an antidepressant prescribed for insomnia. The Assistant Director of Nursing (ADON) acknowledged the missing documentation and emphasized the importance of monitoring sleep to assess the medication's effectiveness. For Resident 285, the facility did not specify the behavior to monitor or the diagnosis related to the use of pimavanserin, an antipsychotic medication. The ADON noted that the staff should have followed up with the prescribing doctor to ensure the order included a specific behavior to monitor and a diagnosis to determine the medication's effectiveness. The facility's policy requires the interdisciplinary team to verify that medication orders include necessary details such as the behavior being treated and monitoring requirements. These deficiencies were identified during a review of the residents' records and interviews with the ADON. The facility's policy on psychoactive medications mandates that the interdisciplinary team ensures all medication orders are complete and include monitoring requirements, which was not adhered to in these cases.
Failure to Label Glucose Test Strips with Opening Date
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services during an inspection of one of two medication carts. Specifically, the deficiency involved an open bottle of glucose test strips on Medication Cart 2 that was not labeled with the date it was opened, as required by the manufacturer's instructions. During an observation and interview, a Licensed Vocational Nurse (LVN) was unable to provide the date the bottle was opened and acknowledged that the licensed nurses were responsible for indicating this date. The purpose of labeling the date is to ensure the glucose test strips are used within 90 days of opening to prevent inaccurate blood glucose readings. Further review with the Assistant Director of Nursing (ADON) confirmed that the manufacturer's instructions required the date of opening to be written on the bottle, and the strips should be used within three months. The facility's policy also indicated that certain medications, including blood sugar testing solutions and strips, require an expiration date shorter than the manufacturer's expiration date to maintain medication purity and potency. The failure to label the glucose test strips with the opening date had the potential to result in inaccurate blood glucose readings, which could affect the insulin dosage administered to residents.
Failure to Adhere to Resident's Dietary Preferences and Needs
Penalty
Summary
The facility failed to ensure that a resident received drinks consistent with their dietary needs and preferences, specifically by serving regular milk, which the resident had indicated as a dislike. This deficiency was observed during a dining observation for a resident on a renal diet, which requires limiting phosphorus intake. The resident's dietary orders included a liberal renal diet with specific dislikes, including regular milk, which was not adhered to by the facility staff. The resident, who had end-stage renal disease and was dependent on renal dialysis, was served regular milk despite it being listed as a dislike on their dietary profile. The dietary supervisor confirmed that the regular milk should not have been served due to the resident's renal diet, which could lead to increased phosphorus levels, negatively impacting the resident's health. Additionally, the meal served did not comply with the double portion order, as only one taco was provided instead of two. Interviews with facility staff revealed a lack of awareness and adherence to the resident's dietary preferences and orders. The Assistant Director of Nursing admitted to not knowing where to check the resident's food preferences, which may have contributed to the oversight. The dietary supervisor acknowledged that the tray was not checked for accuracy before serving, and discrepancies were found between the meal ticket and the dietary profile, leading to the improper serving of regular milk and incorrect meal portions.
Failure to Follow Physician's Diet Order for Resident
Penalty
Summary
The facility failed to ensure that Resident 53 received and consumed foods in the appropriate form and nutritive content as prescribed by the physician and assessed by the interdisciplinary team. The resident, who was admitted with diagnoses including end-stage renal disease, Crohn's disease, and dependence on renal dialysis, was observed to have been served meals that did not comply with the physician's diet order. Specifically, the resident was supposed to receive a consistent carbohydrate, liberal renal diet with double portions at all meals, but was served a single portion and regular milk, which was listed as a dislike and inappropriate for the resident's renal diet. During dining observations, it was noted that the resident was served a meal that included white rice, one carnitas taco, cranberry juice, and almond milk, along with a carton of regular milk, which was not in accordance with the resident's dietary preferences and needs. The Dietary Supervisor confirmed that the meal did not meet the prescribed double portion requirement and that regular milk should not have been served due to the resident's renal condition. The Assistant Director of Nursing admitted to not knowing where to check the resident's food preferences, which may have contributed to the oversight. The facility's policies and procedures indicated that licensed nurses are responsible for documenting and implementing physician orders, and that menus should meet residents' nutritional and personal preferences. However, discrepancies were found between the resident's dietary profile and meal ticket, leading to the incorrect meal being served. The Dietary Supervisor acknowledged that the tray was not checked for accuracy before being served, and the resident's dislikes and double portion instructions were not accurately reflected in the dietary profile.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. A tomato was found on the floor of the walk-in refrigerator, which was acknowledged by the Dietary Supervisor (DS) as a potential source of cross-contamination and foodborne illness. The Director of Nursing (DON) and Registered Dietitian (RD) also confirmed that food should not be on the floor and emphasized the importance of cleanliness to prevent spoilage and pest attraction. The facility's policy and procedure (P&P) indicated that food should be stored off the floor and that storage areas should be regularly cleaned. Additionally, the facility did not have separate thermometer probes inside the reach-in freezers, relying instead on built-in thermometers. The DS was unsure if separate thermometers were required, despite the Food Code 2022 specifying that temperature measuring devices should be located to measure air temperature in refrigerated units. Furthermore, three bags of cereal in the dry storage area were not labeled with expiration or receive dates, and several opened food items that required refrigeration were improperly stored in the dry storage area. The DS, DON, and RD all acknowledged the importance of proper labeling and storage to prevent food spoilage and potential foodborne illness. The facility also failed to ensure proper drying practices for dishware. Drink pitchers were observed stacked while wet in the drying area, which the DS and DON recognized as a potential source of cross-contamination due to water accumulation. The RD emphasized the need for air drying to prevent mildew growth. The facility's P&P highlighted the importance of maintaining sanitation and safety standards, and the Food Code 2022 required that equipment and utensils be air-dried to prevent contamination.
Inaccurate Resident Assessments Lead to Potential Care Delays
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to potential delays in necessary care and services. For one resident, the Minimum Data Set (MDS) did not reflect that the resident was receiving hospice services, despite being admitted to hospice care. This oversight was confirmed by both the MDS Coordinator and the Director of Nursing (DON), who acknowledged that the MDS should have indicated the resident's hospice status to ensure accurate care planning. Another resident's MDS failed to indicate the presence of a feeding tube, despite physician orders and observations confirming the use of enteral feeding. The MDS Coordinator and the DON verified the inaccuracy, noting that the MDS assessments did not reflect the resident's actual nutritional needs. This discrepancy was attributed to the interdisciplinary team's failure to accurately complete their respective parts of the MDS assessment. A third resident's MDS did not document a fall incident that had occurred since the prior assessment, as indicated by the resident's Situation, Background, Assessment, Recommendation (SBAR) form. Both the MDS Coordinator and the DON confirmed the omission, emphasizing the importance of accurate MDS documentation to inform care planning and prevent delays in addressing the resident's needs.
Failure to Prevent Verbal Abuse Between Roommates
Penalty
Summary
The facility failed to prevent verbal abuse between two residents, Resident 1 and Resident 2, who were roommates. On 8/24/2024, Resident 2 verbally abused Resident 1 during an activity session by using profanity and derogatory language. Despite the incident, the residents were not separated until 9/6/2024, which left them at risk for further abuse. The Activities Director (AD) witnessed the incident but did not document it until 9/2/2024 and failed to report it immediately, as required by the facility's policy. Resident 1 was admitted to the facility with diagnoses including major depressive disorder and acute respiratory failure. The Minimum Data Set (MDS) indicated that Resident 1 required assistance with daily activities and could understand and be understood. After the verbal altercation, Resident 1 was assessed for signs of injury and emotional distress, and a care plan was developed to monitor for emotional distress and offer a room change. Resident 2, diagnosed with bipolar disorder and a history of transient ischemic attack, was also involved in the verbal altercation. The MDS indicated that Resident 2 required assistance with personal hygiene and dressing. A care plan was developed for Resident 2 to address the potential for verbal abusive behaviors. The AD admitted to not reporting the incident immediately and only informed the Director of Nursing (DON) after an abuse in-service training. The delay in reporting and separating the residents was acknowledged by the facility's staff as a risk for further abuse.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an alleged abuse incident to the State Survey Agency within the required two-hour timeframe. The incident involved two residents, where one resident verbally abused the other during an activity session. The Activities Director (AD) witnessed the incident but did not report it immediately, instead documenting it several days later. This delay in reporting was contrary to the facility's policy, which mandates immediate reporting of any suspected abuse. Resident 1, who was verbally abused, had been admitted to the facility with diagnoses including major depressive disorder and acute respiratory failure. The resident was dependent on assistance for various daily activities. Resident 2, who was the aggressor, had a history of bipolar disorder and other medical conditions. The incident occurred during an activity session, where Resident 2 used derogatory language towards Resident 1, calling her a demon and making other disparaging remarks. Despite the verbal altercation, the AD did not take immediate action to separate the residents or report the incident to the nursing staff or administration. Interviews with facility staff revealed that the AD did not feel adequately trained in abuse reporting and was unsure if the incident constituted abuse. The delay in reporting and lack of immediate intervention placed both residents at risk for further abuse. The facility's policy clearly outlines the need for immediate reporting of any abuse allegations, but this protocol was not followed, leading to a deficiency in the facility's handling of the situation.
Misappropriation of Resident's Property
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, as evidenced by the unauthorized taking of a resident's cell phone by another resident. The affected resident, who was admitted with a medical history including cerebral infarction, anemia, hyperlipidemia, schizophrenia, dysphagia, muscle weakness, anxiety disorder, hypertension, gastritis, sciatica, and benign prostatic hyperplasia, was moderately cognitively impaired and dependent on staff for personal care. The incident was discovered during a review of video surveillance, which showed another resident taking the phone. Despite the facility's initiation of an abuse protocol, the resident was left without a phone and unable to contact family members. Interviews with the resident and the Director of Nurses confirmed that the facility had not replaced the phone, and the resident's family had to order a new one. The facility's policies on abuse prevention and respect for personal property were reviewed, indicating procedures for protecting residents and their belongings, but these were not effectively implemented in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. On July 17, 2024, at 5:15 a.m., a resident poured lemon juice on another resident's face while they were sleeping, resulting in eye irritation. The affected resident, who had been admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and anxiety disorder, felt defenseless and was unable to sleep following the incident. The resident required moderate assistance for mobility and was dependent on staff for transfers, which contributed to their feeling of helplessness during the altercation. The facility's response to the incident was inadequate. The Social Service Director (SSD) met with the affected resident and documented their feelings of hopelessness and defenselessness, as well as their inability to sleep. However, the SSD did not report these effects to the nursing staff, which could have led to necessary interventions. Additionally, a psychiatry and psychology evaluation was ordered seven days after the incident, but there was no documented evidence that the resident was offered or refused these evaluations. The Assistant Director of Nursing (ADON) acknowledged that the act of pouring juice constituted physical abuse and that the facility failed to address the impact of the altercation on the resident. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from harm and ensuring their dignity and self-determination. Despite these policies, the facility did not take timely or adequate measures to support the affected resident or prevent further harm. The lack of communication between the SSD and nursing staff, as well as the delay in offering psychological evaluations, contributed to the deficiency in care and protection for the resident.
Failure to Provide Adequate Supervision and Individualized Care for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and individualized care for a resident identified as a high fall risk, leading to a significant accident. Resident 3, who had been admitted with chronic obstructive pulmonary disease, muscle weakness, and essential hypertension, was assessed as having moderately impaired cognitive skills and required moderate assistance for mobility. Despite being identified as a high fall risk with a score of 12 on the Fall Risk Evaluation, the facility did not provide the necessary visual supervision while the resident was seated in a Geri-chair in the hallway. The resident's care plan was not adequately reviewed or revised to include person-centered interventions based on the resident's specific risks and conditions. Although the care plan included interventions such as placing the bed against the wall and using a pad alarm, these were not implemented when the resident was in the Geri-chair. The facility's policies on fall management and accident prevention were not followed, as the resident was left unsupervised, resulting in a fall that caused multiple fractures and a head injury. Interviews with facility staff revealed a lack of communication and supervision during the incident. The resident was left unattended in the hallway while staff members were on break or occupied with other tasks. The Assistant Director of Nursing acknowledged the failure to include necessary interventions in the care plan and the lack of visual supervision, which contributed to the resident's fall and subsequent injuries.
Incomplete and Inaccurate Documentation in Resident Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records of two residents, leading to deficiencies in their care. For one resident, the Social Service Director (SSD) did not document the correct date of an altercation with another resident, nor did they document the resident's refusal of a psychologist and psychiatrist evaluation. This lack of documentation suggested that the facility did not offer or provide necessary interventions following the altercation. The SSD acknowledged the inaccuracies in the documentation and the failure to ensure complete and accurate records. In another case, the facility did not document the time Emergency Medical Services (EMS) were notified and when the resident was taken to a hospital after a fall. Additionally, the clinical records inaccurately recorded the notification of the attending physician and family member, listing a date one year prior to the actual incident. The Registered Nurse and Assistant Director of Nursing confirmed the inaccuracies and the potential for delayed services and care due to incomplete documentation. The facility's policies on documentation and notification of changes require accurate and complete records, including the notification of family and responsible parties with the correct name, date, and time. However, these policies were not followed, resulting in incomplete and inaccurate documentation for the residents involved.
Failure to Monitor Facility Temperatures During Extreme Heat
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for seven of nine sampled residents by not monitoring daily temperatures on three consecutive days. Observations on July 3, 2024, revealed that portable air-conditioning units were actively operating in several residents' rooms, indicating a potential issue with the facility's central air-conditioning system. The Maintenance Director (MD) admitted to checking temperatures in only three rooms daily and could not provide documented evidence of temperature checks for July 1, 2, and 3, 2024. The Director of Nursing (DON) was unaware of any downed air-conditioning units and noted that the facility was under an extreme heat advisory, with expected temperatures reaching 108 degrees Fahrenheit. This situation posed a risk to residents' comfort and safety, potentially leading to dehydration. The facility's policy on maintaining a safe environment emphasized the importance of keeping ambient temperatures within a comfortable range to prevent conditions like hypothermia or hyperthermia.
Verbal Abuse Incident Involving Kitchen Coordinator
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically the Kitchen Coordinator (KC), who yelled at the resident to shut up. The incident occurred when the resident, who had been admitted with chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder, approached the Admissions Coordinator (AC) for assistance with a diet slip. The resident's care plan noted a behavior of throwing a dinner tray, and interventions included anticipating and meeting the resident's needs. During the interaction, the KC engaged in a verbal altercation with the resident, which was witnessed by the AC and other staff members. The resident, who was in a wheelchair and required oxygen, felt humiliated and unsafe due to the KC's actions, which included pointing a finger and speaking in a loud, disrespectful manner. The resident expressed feeling agitated and unsafe, fearing potential harm from the KC, who was described as a large man. The facility's investigation revealed that the KC did not have a background check on file, and the incident was reported to the attending physician. The Social Service Coordinator (SSC) and other staff intervened during the altercation, and the resident was informed that the KC was no longer in the facility. The facility's policies on abuse prevention and resident rights emphasize the importance of treating residents with dignity and respect, and ensuring their safety. However, the KC's behavior was deemed inappropriate and unprofessional, failing to uphold these standards. The Administrator acknowledged the potential for residents to feel scared to report similar incidents in the future, highlighting a deficiency in the facility's ability to prevent and address abuse effectively.
Failure to Develop Comprehensive Care Plan for Medication and Shower Refusals
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who refused lactulose medication and showers. The resident, admitted with diagnoses including cirrhosis of the liver, ascites, and essential hypertension, refused lactulose nine times over a six-day period. Despite the multiple refusals, no care plan was developed to address the medication refusal, and the staff did not notify the doctor as required by the facility's policy. The Assistant Director of Nursing (ADON) acknowledged the lack of a care plan and stated that staff should develop one for any refusal of care or medication. Additionally, the resident refused scheduled showers twice in one week, opting for bed baths instead. The Certified Nursing Assistant (CNA) who offered the showers reported that the resident refused due to feeling cold and provided bed baths on both occasions without washing the resident's hair. The CNA did not report the refusals to the nurses, and no care plan was developed to address the resident's refusal of showers. The Infection Preventionist (IP) confirmed that no showers were provided during the specified period and that staff should offer showers first, then provide bed baths if refused, and notify the nurses. The facility's policy on developing and implementing comprehensive care plans, revised in 2023, requires that care plans be person-centered, culturally competent, and trauma-informed, addressing the resident's medical, physical, mental, and psychosocial needs. The policy also mandates that any services not provided due to the resident's refusal be documented. The facility failed to adhere to this policy, resulting in the lack of a comprehensive care plan for the resident's medication and shower refusals.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement infection control measures for Resident 2, who was on enhanced barrier precautions due to a gastrostomy tube (GT). Certified Nursing Assistant 1 (CNA 1) did not wear a protective gown during incontinent care and linen change for Resident 2. CNA 1 was unaware that Resident 2 was on enhanced barrier precautions, as there was no signage in the room on a previous date, and CNA 1 did not receive a report indicating the need for enhanced barrier precautions. Licensed Vocational Nurse 1 (LVN 1) was also not informed that Resident 2 was on enhanced barrier precautions. LVN 1 did not receive a report from the outgoing shift about Resident 2's status, which is crucial to prevent the spread of infection. The lack of communication and proper reporting between shifts contributed to the failure in implementing the necessary infection control measures. The Infection Preventionist (IP) confirmed that staff had been in-serviced about the need for enhanced barrier precautions for residents with tubings, catheters, or wounds. The IP stated that residents on enhanced barrier precautions should have signage posted in their rooms and wear an orange bracelet. Despite these protocols, the facility did not ensure that all staff were aware of and adhered to the enhanced barrier precautions for Resident 2, leading to potential cross-contamination and infection risks among residents.
Failure to Notify POA of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of a resident regarding the progression of an abrasion over the resident's coccyx. The resident, who had diagnoses including dementia, cerebral infarction, bipolar disorder, and morbid obesity, was severely impaired with thought processes and decision-making tasks. The facility's records indicated that the resident's daughter was the designated POA. On a specific date, a Licensed Vocational Nurse (LVN) noted an abrasion on the resident's coccyx and attempted to contact the POA but was unable to leave a message due to a full voicemail box. However, the POA later stated that her voicemail was not full and that she was not informed of the wound during her frequent visits to the facility. The Director of Nursing (DON) acknowledged that the facility should have made additional attempts to contact the POA or tried another number. The Registered Nurse Supervisor (RNS) admitted that she forgot to document the call attempt and did not relay the need for follow-up to the next shift. The LVN confirmed that she had reported the change of condition to the medical doctor and the treatment nurse but had only endorsed the follow-up call to the RNS. The facility's policy required notifying the resident's representative of significant changes in health status, which was not adequately followed in this case. The POA discovered the wound during a doctor's appointment and was informed by the facility staff that the wound had been present for several weeks. This lack of communication prevented the POA from requesting additional care interventions for the resident. The facility's failure to properly notify the POA of the resident's change in condition violated the resident's rights to be fully informed and to have their representative involved in their care decisions.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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