Feather River Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oroville, California.
- Location
- 1 Gilmore Lane, Oroville, California 95966
- CMS Provider Number
- 055612
- Inspections on file
- 47
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Feather River Care Center during CMS and state inspections, most recent first.
Two residents with heel and foot ulcers received wound care from an LVN who used the same pair of reusable scissors to cut specialized dressings for each resident’s wounds without cleaning or disinfecting the scissors between uses, contrary to facility policy requiring disinfection of multi‑resident equipment after each use; both residents also reported limited assistance with basic hygiene such as showers and access to washcloths for face and hand care.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was subjected to two separate incidents of non-consensual touching by another cognitively intact resident, who was observed rubbing the resident’s side while grunting and later touching the resident’s chest. Staff documented the first event only in the alleged perpetrator’s chart, did not report it as abuse, and did not complete a nursing evaluation or change-in-condition assessment for the victim, despite facility policy requiring immediate protection, assessment, and increased supervision. After the second witnessed incident, nursing staff and the IP confirmed that no full nursing evaluation of the victim was performed. The DON was informed by text of the first incident but directed the RN only to write a progress note, and the Administrator later acknowledged he had not been notified of the first event, that there was no clear plan to keep the two residents apart, and that the alleged perpetrator continued to move unsupervised throughout the unit, including near the victim’s room.
The facility failed to follow its abuse policy when staff reported that a cognitively intact male resident was observed rubbing the side of a severely cognitively impaired female resident while grunting. The RN on duty documented the event only in the male resident’s chart and a communication report, did not assess or document on the female resident, did not initiate a change in condition assessment, and did not report the allegation as abuse to the Admin or required agencies. No specific protective interventions or supervision plan were implemented to keep the male resident away from the female resident, and he continued to move independently in his wheelchair without direct staff supervision. A subsequent incident occurred in which staff witnessed the male resident touching the female resident’s chest area, and the Admin later confirmed the earlier event had not been reported and that there was no solid plan to supervise or separate the residents.
The facility failed to develop and implement individualized smoking safety care plans for four cognitively intact residents known to smoke, despite a policy requiring safe smoking measures to be documented in each care plan and followed in designated smoking areas. Record reviews showed that care plans lacked resident-specific interventions for smoking supervision, designated locations, or safety precautions, even when one resident had documented COPD, substance dependence, and elopement-like behaviors related to smoking, and another had nicotine dependence and mobility issues. Interviews revealed that residents were instructed to go off property to smoke or went outside alone, sometimes over uneven terrain and in cold weather, without staff supervision or a designated smoking area, while an RN and the Administrator confirmed the absence of smoking-related care plan directions or authorized smoking orders.
The facility failed to follow its own smoking and smoke‑free policies, which require a designated smoking area with posted signage and restrict smoking to that area. Four residents who smoke were instead instructed by staff to leave facility property to smoke, with cigarettes stored on the med cart and signed out before departure. One resident was observed independently wheeling across uneven terrain in cold weather to an off‑property location to smoke without staff supervision, and other residents reported propelling themselves in wheelchairs to a public sidewalk or up a hill off the grounds to smoke, sometimes being told to remain out of sight. No designated smoking area or signage existed on or off the property, despite policy requirements and staff and administrator acknowledgment that residents were smoking outside the facility.
A Licensed Vocational Nurse was found to have an inactive license, which was not identified until a monthly license verification was conducted. The DON confirmed that license checks are usually performed monthly but was not diligent in this instance, resulting in the nurse working with an inactive license until the issue was discovered and the nurse was removed from the schedule.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident with multiple medical conditions was physically struck in the eye by another resident following a verbal altercation, resulting in a bruised eye and discomfort. Staff confirmed the incident as physical abuse, and the facility's policy requiring prevention of abuse was not effectively implemented.
Nursing staff did not promptly recognize or report a significant change in condition for a resident with multiple complex diagnoses, resulting in delayed acute care treatment and eventual hospital transfer. The resident experienced a notably low blood pressure, and despite a physician order to push fluids, there was no timely escalation or evaluation. The DON confirmed that facility policy was not followed, leading to the resident's extended hospital admission and dissatisfaction with care.
A resident who spoke only Hmong and had significant medical needs was not provided with any translation services or communication aids. Staff and family confirmed that the facility had no way to communicate with the resident, resulting in the resident not being properly assessed and her pain not being treated.
A resident with hemiplegia and hemiparesis suffered an injury after slipping in a shower chair, resulting in a cut and visible pain, which was witnessed by staff and family. Despite clear signs of pain, no documentation, physician notification, or pain management interventions were provided, and the event was omitted from the medical record, leaving the resident without pain relief.
A resident with hemiplegia and dysphagia, who communicates only in Hmong, suffered a leg injury after slipping into a shower chair. Nursing staff did not assess, document, or notify the physician about the injury, nor was pain addressed or a care plan updated. Family members and staff confirmed the incident and the resident's pain, but no pain medication was given and the event was not recorded in the medical record.
A resident with a history of aggression and mental health issues, who was not properly assessed or care planned for behavioral health needs, pushed another resident out of her wheelchair while under 1:1 monitoring. The incident occurred despite facility policy requiring assessment and intervention for residents with behaviors that could lead to conflict, and the interdisciplinary team did not address the altercation until several days later.
A resident admitted from another SNF with documented depression, Bipolar II disorder, and prescribed sertraline did not have their PASRR reassessed or validated by facility staff. The previous PASRR inaccurately indicated no serious mental illness or psychotropic medication use, and staff confirmed they did not verify its accuracy, resulting in no behavioral health care plan for the resident.
A resident with a history of depression, Bipolar II disorder, and recent psychological care was admitted without a behavioral health care plan, despite documented aggression, agitation, and suicidal ideation. The facility did not provide mental health appointments or address these needs in the care plan, leading to multiple behavioral incidents, including a resident-to-resident altercation while under 1:1 monitoring.
A resident with a history of psychiatric and behavioral health needs was admitted without proper behavioral health evaluation or services, despite documented diagnoses and prior psychological care. The facility did not reassess or validate previous mental health screenings, failed to develop a behavioral health care plan, and did not arrange mental health appointments. This led to escalating behavioral incidents, including aggression, self-harm, and a resident-to-resident altercation, ultimately resulting in the resident's transfer to a hospital for psychiatric evaluation.
A resident with schizophrenia under a court-appointed conservator had her antipsychotic medication changed without the conservator's knowledge or consent, contrary to facility policy and legal requirements. The conservator was not informed of the risks, benefits, or alternatives to the medication change, and documentation was lacking. This led to a decline in the resident's mental health and subsequent hospital readmission.
A resident with a history of aggressive behavior was involved in an altercation, leading the provider and IDT to recommend 1:1 monitoring. Although a CNA was assigned to monitor the resident, the care plan was not updated to include this intervention, contrary to facility policy. The DON confirmed the care plan should have reflected the 1:1 monitor after the incident.
The facility failed to maintain proper infection control practices, as a CNA wore the same isolation gown while caring for two residents, one with C-diff. Additionally, there was no dedicated cleaning equipment for the C-diff resident's bathroom, and the nurse's station counter was damaged, preventing proper disinfection. These issues were confirmed by staff, highlighting a breach in infection prevention protocols.
A resident frequently entered the rooms of five other residents uninvited, violating their privacy rights. Despite being aware of the issue, the facility staff, including the DON and CNAs, did not implement effective measures to prevent these intrusions. The affected residents, some with cognitive deficits and others cognitively intact, expressed discomfort and dissatisfaction with the situation.
A resident with cognitive intactness and a history of hemiplegia was not provided adequate foot care due to the facility's failure to assess and document the condition of the resident's feet. The LN did not notify the physician or develop a care plan, leading to the resident experiencing discomfort and frustration. Observations showed long, thick, discolored toenails and dry, flaky skin, with no foot care treatments ordered.
A resident with dementia and a history of falls was found unsupervised in a shower room, resulting in a fall due to an unlocked door. The facility failed to provide required one-to-one supervision and did not document the resident's wandering behavior accurately in the MDS assessment, compromising the resident's safety.
A resident admitted with hemiplegia and hemiparesis following a stroke did not receive a necessary follow-up appointment with a vascular surgeon due to the absence of social services staff at the time of admission. The interdisciplinary team failed to ensure the referral was made, despite discharge documents indicating the need for an appointment within a week.
The facility's dietary department was found deficient due to an unlabeled storage bin with sugar and four bins with visible dust and adhesive residue on the lids. The Dietary Manager confirmed these issues, which were against the facility's policies on cleanliness and labeling.
The facility was found non-compliant with regulations limiting resident room capacity to four individuals, as one room contained five beds. Despite adequate privacy and storage, this setup violated standards. The Administrator noted the ongoing waiver renewal request.
A resident in a facility was found without access to a call light, which was not within reach, potentially delaying care. The resident, who had multiple health issues and was dependent on staff for daily activities, was observed yelling for help. The call light was improperly positioned, contrary to the facility's policy, and was confirmed by staff to be inaccessible.
A resident, who was cognitively intact and had multiple medical conditions, experienced a violation of their rights when a staff member was rude and disrespectful during an inquiry about lost clothing. The Maintenance Supervisor yelled at the resident and incorrectly claimed the clothing was not labeled. The facility's policies on resident rights and dignity were not followed, as confirmed by the Administrator and DON.
A resident's needs were not accommodated when a bedside table used for art supplies was removed without consent, leading to frustration and anger. The Maintenance Supervisor took the table for another resident due to a shortage, and the Administrator and DON confirmed the removal was not handled appropriately.
A facility failed to update a resident's care plan to reflect new pain management needs. The resident, with rheumatoid arthritis and other conditions, expressed discomfort due to pain when touched at night. Despite new medication orders for Methotrexate and Prednisone, the care plan was not revised to include these or the resident's specific repositioning preferences. Interviews confirmed the oversight, resulting in unrecognized care needs.
A resident with Rheumatoid Arthritis and spinal stenosis did not receive consistent daily hair care assistance, as required by the facility's policy. Documentation showed inconsistencies in the level of assistance provided, and observations revealed the resident's hair was not properly maintained. The resident expressed dissatisfaction, and a CNA confirmed the lack of appropriate supplies for hair care. The DON acknowledged the need for daily assistance due to the resident's reduced fine motor skills.
The facility failed to protect the dignity and rights of six residents by not responding to call lights and delaying pain medication administration. A resident experienced an argument with an LVN over medication, while another on hospice care faced significant delays in receiving pain relief, increasing her anxiety and pain. Other residents reported long wait times for assistance, particularly during the night shift, leading to feelings of anger, sadness, and fear.
The facility failed to provide timely care for activities of daily living, leaving a resident in a soiled brief for 12 hours due to short-staffing and lack of CNA assignment. Two other residents also reported not being changed regularly, highlighting issues with staffing and communication during shift changes.
Two residents reported feeling unsafe due to the disrespectful behavior of an LVN, who yelled at one resident for requesting pain medication and refused to change another's bandage. The LVN was terminated after multiple complaints and observations of inappropriate conduct, violating the facility's policy on resident rights.
A deficiency occurred when a staff member closed a resident's door and silenced the call light, against facility policy. The resident, with severe cognitive impairment and a history of trauma, was vulnerable to isolation. The LVN involved admitted to closing the door and adjusting the call light system, although she denied disconnecting wires. The DON confirmed an investigation was underway, and the LVN was removed from duty.
A resident with multiple medical conditions was left with soiled dressings and a bloody shirt while eating meals, despite requesting assistance. A CNA informed an LN, who acknowledged the need for dressing changes but had not yet acted. The DON confirmed the dignity issue, stating they were unaware until informed.
A resident was admitted with multiple medical conditions, including sepsis and cellulitis, but the facility failed to obtain necessary physician orders for wound care. The admission records were incomplete, lacking orders for open wounds on the resident's body. Interviews with staff, including the DON and MD, confirmed the oversight, revealing a lack of communication and documentation. Staff admitted to not performing necessary assessments, leading to a delay in care.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with serious health conditions, as required by their policy. The absence of this care plan was confirmed through medical record reviews and staff interviews, indicating that staff lacked necessary information to address the resident's specific needs.
The facility failed to maintain comfortable temperatures in six resident rooms, with temperatures ranging from 82.6 to 90.3 degrees Fahrenheit. A resident with a history of acute myocardial infarction and respiratory failure felt hot and uncomfortable due to the HVAC unit malfunction and circuit overloads caused by portable air conditioners.
The facility failed to maintain comfortable room temperatures, affecting several residents. Despite repairs to the main air conditioning units, room temperatures exceeded the facility's policy range. Residents reported discomfort, and attempts to use swamp coolers and portable air conditioners were ineffective due to improper use and electrical issues. Staff and family members confirmed the ongoing temperature problems, with the HVAC system requiring further repairs.
A resident with multiple health conditions did not receive privacy during a medical procedure. An LVN entered the room to administer medication while the Maintenance Director and a surveyor were present. The LVN exposed the resident's body without using a privacy curtain. The LVN admitted to not considering privacy during the procedure.
A facility failed to ensure accurate resident assessments, as an MDS inaccurately indicated a resident had an indwelling catheter. This was confirmed through staff interviews and record reviews, revealing the resident did not have the catheter, potentially impacting their care.
The facility failed to develop a comprehensive care plan for a resident who frequently removed their clothes. Despite staff acknowledging the behavior, no interventions were documented to manage it, leading to inadequate care and services for the resident's well-being.
A resident with a history of renal disease and muscle weakness exhibited UTI symptoms, including dark and foul-smelling urine, vomiting, and bladder pain. Despite receiving an order for a urinalysis (UA) and urine culture sensitivity test (C&S) on 3/8/2024, the facility failed to collect the UA until 3/10/2024. The delay in testing and lack of documentation potentially delayed the resident's treatment.
Failure to Disinfect Reusable Scissors Between Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policy for cleaning and disinfecting reusable, non‑critical equipment between residents. The written policy dated 1/1/2026 states that multiple‑resident use equipment shall be cleaned after each use. During surveyor observation, an LVN performed wound care on a resident with a left heel pressure ulcer. The LVN used a pair of scissors taken from her pant pocket to cut a special dressing (Calcium Alendronate) for the wound and then returned the uncleaned scissors to her pocket after completing the dressing change. No cleaning or disinfection of the scissors was performed after use on this resident. Shortly afterward, the same LVN performed wound care on the roommate, a resident with a diabetic ulcer on the right foot. The LVN again retrieved the same scissors from her pant pocket and used them to cut the special dressing for the second resident’s wound without having cleaned or disinfected the scissors between uses. The LVN then placed the scissors back into her pocket without cleaning them. In interviews, the first resident reported having heel wounds and receiving only sponge baths twice a week without being routinely offered washcloths for face and hand hygiene, and the second resident reported having a diabetic foot ulcer and needing to ask for basic care items such as washcloths. In a post‑observation interview, the LVN acknowledged forgetting to sterilize the scissors between residents and stated that the standard is to sterilize equipment between residents, and the Infection Preventionist confirmed that the expectation is to disinfect instruments between residents.
Failure to Protect Resident From Repeated Sexual Contact and to Follow Abuse Policy
Penalty
Summary
The facility failed to protect a resident from sexual abuse and to follow its own abuse, neglect, and exploitation policy after two separate incidents of non-consensual touching by another resident. The policy defined abuse to include certain resident-to-resident altercations and required immediate protection of the alleged victim, examination for injury or psychosocial harm, increased supervision, and emotional support. Despite this, after staff observed one resident sitting next to another and rubbing her side while grunting, the nurse documented the event only in the alleged perpetrator’s chart and did not report it as abuse, did not complete a nursing evaluation or change-in-condition assessment for the alleged victim, and did not initiate protective interventions as outlined in the policy. The alleged victim, Resident 1, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, and her most recent MDS showed severely impaired cognition with a BIMS score of 5. The alleged perpetrator, Resident 2, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with intact cognition and a BIMS score of 14. Staff documented that on one date Resident 2 was seen touching Resident 1’s side and grunting, and on a later date staff witnessed Resident 2 touching Resident 1’s chest area. The second incident was recorded in an IDT note, but nursing staff confirmed that Resident 1 was not given a full nursing evaluation after this incident, and the Infection Preventionist also confirmed that Resident 1 was not evaluated by nursing staff after the second event. Multiple staff interviews confirmed that the facility did not implement its abuse policy to protect Resident 1 after either incident. The LVN and RN involved acknowledged that no full evaluation of Resident 1 was completed after the second incident, and one RN stated he was unaware he should have done so per policy. Another RN stated she did not feel compelled to report the first incident as abuse because she had not personally witnessed it and only wrote a progress note in Resident 2’s chart after being told to do so, with no documentation for Resident 1. The Administrator reported he was not informed of the first incident, confirmed there was no solid plan to keep Resident 2 away from Resident 1, and acknowledged that Resident 2 continued to move throughout the facility in his wheelchair without direct supervision, including to the area outside Resident 1’s room, while no specific protective measures were in place for Resident 1.
Failure to Report and Protect After Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse and to protect a resident after staff observed inappropriate physical contact between two residents. Facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours when abuse is involved. The policy also required immediate protective measures for alleged victims, such as increased supervision and emotional support. Despite this, an RN documented on 12/20/25 that staff reported a cognitively intact male resident sitting next to a severely cognitively impaired female resident, touching her side and grunting, and only noted to monitor behavior. Resident 1, the alleged victim, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, with a recent MDS showing severely impaired cognition (BIMS score of 5). Resident 2, the alleged perpetrator, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with an intact cognition (BIMS score of 14). On 12/20/25, RN A documented in Resident 2’s progress notes and the facility communication report that staff saw Resident 2 rubbing Resident 1’s side while grunting, and that the residents were separated. However, RN A did not complete a nursing evaluation, did not document in Resident 1’s record, did not initiate a change in condition assessment, and did not report the allegation as abuse per facility policy, stating she did not feel compelled to report because she had not personally witnessed the interaction and that she only entered a progress note as directed. On 12/22/25, a subsequent incident occurred in which staff witnessed Resident 2 touching Resident 1’s chest area, as documented in an IDT note dated 12/23/25. During observation on 12/23/25, Resident 1, in bed, could not recall the incidents but stated that something had happened that was not good. Resident 2 was observed ambulating independently in his wheelchair without direct staff supervision, including to the area outside Resident 1’s room. In an interview, the Administrator stated he was unaware of the 12/20/25 incident because nursing staff failed to notify him, confirmed the incident was not reported per facility policy, and acknowledged that no solid plan or specific interventions were implemented to supervise Resident 2 or keep him away from Resident 1, despite knowing that Resident 2 moved throughout the facility in his wheelchair without supervision. The Administrator also confirmed that the 12/20/25 incident could have led to the escalation and the 12/22/25 incident.
Failure to Develop Individualized Smoking Safety Care Plans for Smoking Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, measurable care plans addressing smoking safety for four cognitively intact residents known by the facility to smoke. The facility’s own “Resident Smoking - Smoke-Free Facility” policy required that any resident deemed safe to smoke, with or without supervision, do so only in designated smoking areas in accordance with the resident’s care plan, and that all safe smoking measures be documented in the care plan and communicated to staff, visitors, and volunteers. Despite this, record reviews on 12/19/25 showed that the care plans and physician orders for Residents 1, 2, and 3 lacked documented, individualized interventions for safe smoking practices, including supervision requirements, designated smoking areas, or other smoking-related safety measures. Resident 4’s care plan addressed smoking cessation only and did not contain interventions or physician orders for safe smoking practices. Resident 1 was admitted with COPD, tobacco use, alcohol abuse, ataxia following cerebral infarction, and psychoactive substance dependence with intoxication delirium, and had a BIMs score of 15, indicating intact cognition. An IDT progress note dated 12/17/25 documented that, despite education, this resident continued to smoke on facility grounds, had been observed smoking near hazardous areas, and was sneaking out multiple times during the day and night. The note also documented refusal of nicotine patch therapy and stated the care plan was to be updated to reflect elopement risk, substance use behaviors, and refusal of nicotine replacement therapy; however, the care plan dated 11/26/25 did not indicate elopement risk or any safe smoking plan. Resident 2, with schizoaffective disorder, muscle weakness, and frontal lobe/executive function deficit and a BIMs score of 15, also had no safe smoking plan in the care plan dated 12/12/25. In interview, this resident reported smoking cigarettes and stated he had been told he must go off the property to smoke because smoking was not allowed, and expressed feeling that staff did not care about him or what he wanted. Resident 3, admitted with pleural effusion, malnutrition, nicotine dependence, difficulty walking, and kidney disease and a BIMs score of 14, had a care plan dated 11/19/25 that did not address safe smoking. In interview, this resident reported going outside alone to smoke 1–2 times a day, leaving oxygen in the room, and stated he had been signed off by physical therapy as safe to go outside independently, but wished he did not have to go so far to smoke. Resident 4, admitted with diabetes, COPD, muscle weakness, and difficulty walking and a BIMs score of 15, had no care plan or physician orders authorizing or directing safe cigarette smoking practices. During concurrent interview and record review, RN A confirmed the absence of such documentation, stated awareness of the non-smoking policy, and reported that she believed residents went around the corner of the building to smoke but that she had not supervised residents while smoking. Observation showed Resident 4 independently wheeling himself across uneven terrain in cold weather to an off-property area to smoke, without staff supervision or redirection, and this location was not a designated smoking area. The Administrator confirmed awareness that these four residents smoked, acknowledged there was no designated smoking area at that time, and confirmed that none of the four residents had individualized cigarette smoking safety care plans addressing supervision, location, or safety measures.
Failure to Implement Smoking Policy and Provide Designated Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own smoking policies, which require that residents deemed safe to smoke may do so only in designated smoking areas, at designated times, and in accordance with their individualized care plans. The facility’s smoke-free policy also states that smoking, including e‑cigarettes, is prohibited in all areas except a designated smoking area, and that a designated smoking area sign will be prominently posted. Surveyors reviewed these policies and then observed that there was no designated smoking area or signage on or off facility property. The Administrator acknowledged awareness that four residents smoke outside the facility and confirmed that the facility was not following its smoke-free policy because no designated smoking area had been established. Surveyors identified four residents as smokers. A RN reported that the facility is a non‑smoking facility and that residents who smoke are instructed to leave the property to do so, with their cigarettes stored in the medication cart and signed out on a log before they leave. One resident was observed independently wheeling himself in a wheelchair across uneven terrain in cold weather to an off‑property location to smoke, without staff supervision or redirection, and this location was not identified as a designated smoking area. Another resident stated he obtains cigarettes from nursing staff and is instructed to go to the public sidewalk along the street to smoke and to remain out of sight while smoking. A third resident reported he smokes twice per day and must propel himself in his wheelchair up a hill and off facility grounds to smoke, having been informed the facility is non‑smoking and that residents must go off grounds. A smoking assessment for another resident documented that the resident smokes, does not follow the non‑smoking policy, was determined able to smoke independently, and had been educated on the facility’s smoking policies and risks, yet the facility still lacked a designated smoking area as required by its own policies.
Failure to Ensure LVN Maintained Active License
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) maintained a current and active license in accordance with state law. A review of the Board of Vocational Nursing and Psychiatric Technicians licensure report showed that the LVN's license was inactive, meaning the licensee was not permitted to practice in California, even though the license had not yet expired. The facility's policy required verification of licensure status through the appropriate agency and assigned responsibility for maintaining valid licensure to the Human Resources Director or designee, as well as to the licensed employee. Interviews with the Administrator and Director of Nursing (DON) confirmed that the LVN's license became inactive toward the end of August and that this was discovered during a routine monthly license lookup. The DON acknowledged that license reviews are typically conducted at the end of each month but admitted to not being on top of the process in this instance. The LVN was subsequently removed from the work schedule after the inactive status was identified.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the right eye with a closed fist. The incident occurred after the first resident, who has multiple medical conditions including multiple sclerosis, dementia, and depression, asked the second resident to stop talking loudly and to leave the room. The first resident admitted to possibly yelling due to being hard of hearing, after which the second resident, who also has several medical and psychiatric diagnoses including bipolar disorder and depression, reacted by hitting him. The altercation resulted in the first resident sustaining a bruised right eye and experiencing discomfort for several days. Staff interviews confirmed that yelling was heard from the room, and by the time staff arrived, the physical altercation had already taken place. The resident who was struck was sent to the hospital for evaluation of his injury. Both the DON and the facility administrator confirmed that the incident constituted physical abuse. The facility's policy on abuse, neglect, and exploitation requires the prevention of such incidents, but in this case, the policy was not effectively implemented to protect the resident from harm.
Failure to Recognize and Report Change in Condition Resulting in Delay of Care
Penalty
Summary
Nursing staff failed to recognize and report a significant change in condition for one of eight sampled residents, who had multiple complex medical diagnoses including atrial fibrillation, aortic valve disorder, bilateral pneumonia, COPD, and several mental health conditions. The resident was cognitively intact and responsible for their own care decisions. On the date in question, the resident's blood pressure was recorded at a significantly low level (82/64 mmHg), with documentation noting the abnormal value but lacking details such as multiple measurements or the resident's position during assessment. Although there was a physician order to push fluids, there was no documentation indicating that the resident was sent for further evaluation at that time. Later that evening, police were called to the facility, and after discussions with the resident and their daughter, the resident requested to be sent to the hospital due to concerns about a possible allergic reaction. The medical director was notified, and EMS was called to transfer the resident. The Director of Nursing confirmed that the facility's policy for notification of changes in condition was not followed, and acknowledged that the resident experienced a delay in care and should have been sent to the hospital earlier. The resident was subsequently admitted to a local hospital for an extended period and expressed dissatisfaction with the care received at the facility.
Failure to Provide Translation for Non-English Speaking Resident
Penalty
Summary
The facility failed to accommodate the communication needs of a resident who spoke only Hmong and was her own representative. The resident was admitted with hemiplegia, hemiparesis following a cerebral infarction, and dysphagia. Record review indicated that the resident had a communication deficit due to a language barrier, and the care plan noted that social services provided a picture binder for communication, with an intention to provide a communication board. However, during multiple interviews with staff, family members, and direct observation, it was confirmed that the facility did not provide any means of translation or communication aids for the resident. Staff, including the DON, CNAs, and a nurse, all stated that there was no way to translate or communicate with the resident, and family members confirmed that the only attempts at translation involved asking family to assist. No communication boards or picture aids were found in the resident's room, and the resident was rarely or never understood according to the MDS assessment. As a result, the resident was not properly assessed and her pain was not treated.
Failure to Address and Treat Resident Pain After Shower Chair Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, and dysphagia, who only spoke Hmong, experienced an accident while in a shower chair. The resident slipped and became stuck in the chair, resulting in a cut and visible injury to the right thigh. Multiple staff, including CNAs and nurses, witnessed the incident and observed the resident expressing pain both verbally and through facial grimacing. Family members also confirmed that the resident complained of pain following the incident. Despite clear evidence of injury and pain, there was a complete lack of documentation or follow-up in the resident's medical record. No accident or injury was recorded in the electronic medical record, and there were no notes from social workers, no physician consultation, no psychosocial follow-up, and no updates to the care plan. The Medication Administration Record showed no administration of new pain medication after the incident, and pain scores were recorded as zero each day, despite staff and family reports of pain. Interviews with staff revealed that the incident was known to the Director of Nursing and other nursing staff, but no one documented the event or addressed the resident's pain. The facility's pain management policy required recognition and evaluation of pain, especially after significant changes in condition, but these steps were omitted. The resident suffered without any pain relief or appropriate clinical response following the injury.
Failure to Assess, Document, and Treat Resident Injury Following Shower Chair Accident
Penalty
Summary
Nursing staff failed to assess, document, and respond appropriately when a resident with hemiplegia, hemiparesis, and dysphagia experienced an accident while being transferred in a shower chair. The resident, who only speaks Hmong and is rarely understood, slipped into the opening of the shower chair, resulting in her right leg being caught and sustaining a cut on her right thigh. Despite the resident expressing pain verbally and through facial grimacing, there was no documentation of the incident or injury in the medical record, and no pain assessment or treatment was provided. Interviews with staff revealed that the CNA present during the incident observed the injury and pain but did not document the event. The DON and assigned nurses were either unaware of the incident or could not recall details, and no one completed a change in condition assessment or notified the physician as required by facility policy. The Medication Administration Record showed no pain medication was administered, and pain scores were recorded as zero following the incident. Additionally, the care plan was not updated to address the accident or injury. Family members confirmed being informed of the accident and noted the resident's complaints of pain. Observations days after the incident revealed visible scabbing and injury to the resident's right thigh. The Infection Preventionist acknowledged that the accident and injury were not addressed by nursing staff or the facility, indicating a failure to ensure staff had the competencies and skills necessary to provide appropriate care and documentation for the resident.
Failure to Protect Resident from Abuse Due to Inadequate Behavioral Assessment and Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another out of her wheelchair, resulting in the latter falling to the floor. The facility's policy requires the identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect. However, the admission team did not identify that the resident who committed the abuse had Bipolar II disorder or that he had been receiving psychological care at his previous facility. There were no behavioral health care plans in his record, nor were any mental health appointments provided to him after admission. The resident had a history of aggression, agitation, and suicidal ideation, as documented in multiple progress notes, and was placed on 1:1 monitoring after expressing self-harm and aggressive behaviors. Despite being under continuous 1:1 monitoring, the resident was able to approach another resident in the hallway and push her out of her wheelchair. The interdisciplinary team did not meet to discuss the altercation until six days after the event. The resident who was pushed had severe cognitive impairment and was significantly dependent on caregivers. The Director of Nursing confirmed gaps in the identification and care planning for the resident with behavioral health needs, as well as a lack of awareness of his mental health status and history upon admission.
Failure to Validate PASRR Accuracy for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident who was admitted from another skilled nursing facility. Upon admission, the staff did not validate or reassess the PASRR that had been completed at the previous facility, despite the resident having documented diagnoses of depression and Bipolar II disorder, as well as being prescribed sertraline, a psychotropic medication. The PASRR from the prior facility indicated no diagnosed or suspected serious mental illness and no psychotropic medication use, which was inconsistent with the resident's medical record and ongoing treatment. Interviews with facility staff, including the DON and Social Services Director, confirmed that the admission team did not reassess or validate the PASRR upon the resident's admission. The staff relied on the previous PASRR without verifying its accuracy, resulting in the absence of a behavioral health care plan for the resident, despite clear evidence of mental health diagnoses and treatment in the resident's record.
Failure to Develop and Implement Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the mental health and behavioral needs of a resident with a history of depression and Bipolar II disorder. Upon admission, the resident's records indicated diagnoses of stroke, depression, and Bipolar II disorder, as well as recent participation in multiple psychology appointments at a previous facility. The Minimum Data Set (MDS) assessment identified moderate cognitive impairment and mild depression, but these findings were not incorporated into a behavioral health care plan. Despite documented episodes of aggression, agitation, and suicidal ideation, there was no care plan in place to address the resident's mental health needs. The resident exhibited threatening behavior toward staff, self-harm, and made multiple statements about wanting to end his life. The facility's Social Services Director and Director of Nursing confirmed that no behavioral health care plan was developed, and the resident did not receive mental health appointments after admission. The Social Services Director also acknowledged being behind on developing the resident's plan of care. While under 1:1 monitoring due to suicidal ideation, the resident was able to initiate a physical altercation with another resident, resulting in harm. The lack of a comprehensive care plan addressing the resident's behavioral and mental health needs contributed to these incidents, as the facility did not follow its own policy requiring measurable objectives and timeframes for all identified needs.
Failure to Provide Behavioral Health Services Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a history of psychiatric and behavioral health needs received appropriate behavioral health evaluation and services upon admission. The resident was transferred from another skilled nursing facility with diagnoses including stroke and depression, and had a documented history of Bipolar II disorder and recent psychology appointments. However, upon admission, the facility did not validate or reassess the previous PASRR, which had not identified serious mental illness or psychotropic medication use, nor did they recognize the resident's ongoing mental health needs as indicated in the transfer records and initial assessments. Despite the resident's moderate cognitive impairment and mild depression identified on the MDS and PHQ-9, there was no behavioral health care plan developed, and no mental health appointments were provided after admission. The DON confirmed that the admission team did not identify the resident's Bipolar II disorder or prior psychological care, and the Social Services Director stated that the PASRR from the previous facility was not validated for accuracy. The lack of behavioral health interventions and follow-up contributed to the resident's escalating behavioral symptoms, including aggression, threats of self-harm, and agitation. These unaddressed behavioral health needs culminated in multiple incidents, including threats to staff, self-injurious behavior, and a resident-to-resident altercation where the resident shoved another resident out of a wheelchair. The situation escalated to the point where the resident required 1:1 monitoring and was ultimately transferred to the hospital for psychiatric evaluation after repeated self-harm attempts and aggressive behavior, despite being under continuous observation.
Failure to Obtain Conservator Consent for Antipsychotic Medication Change
Penalty
Summary
The facility failed to inform the court-appointed conservator of a resident with schizophrenia about the risks, benefits, and alternatives to a proposed medication change, as required by both facility policy and the resident's legal status. The resident, who was under an LPS conservatorship due to a serious mental illness and inability to make medical decisions, was admitted to the facility while receiving Clozapine for schizophrenia. Shortly after admission, Clozapine was placed on hold for an unknown reason, and the resident was instead prescribed Paliperidone. The informed consent form for Paliperidone was signed by the resident and staff, but not by the conservator, who was the legally authorized decision-maker. Facility records and interviews confirmed that the conservator was not notified or consulted prior to the medication change or discontinuation of Clozapine. Staff interviews revealed uncertainty about why the medication was held and acknowledged that the conservator's consent was not obtained, despite the resident's long-standing conservatorship and the facility's own policies requiring such notification and consent for psychotropic medication changes. The conservator was only made aware of the situation after the resident's mental health had deteriorated. As a result of the lack of communication and failure to obtain proper consent, the resident experienced a decline in mental health status, necessitating hospital readmission for treatment of schizophrenia. Documentation did not provide a rationale for the medication change, nor did it show that the conservator was informed or involved in the decision-making process, as required by both policy and legal mandate.
Failure to Update Care Plan with 1:1 Monitor After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to update the care plan for a resident with a history of aggressive behavior following an incident in which the resident struck another resident. Despite the provider's recommendation and the Interdisciplinary Team's (IDT) decision to implement a 1:1 monitor after the incident, this intervention was not added to the resident's care plan. The care plan continued to list previous interventions such as allowing the resident to express concerns, approaching calmly, and consulting psychiatry as needed, but did not reflect the new 1:1 monitoring requirement. Record reviews and staff interviews confirmed that the 1:1 monitor was being implemented in practice, as a CNA was assigned to monitor the resident, but this intervention was not documented in the care plan as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated during the IDT meeting and confirmed that the omission was not in line with facility expectations or policy, which requires care plan revisions upon a change in resident status.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by several deficiencies in infection prevention and control practices. A Certified Nurse Assistant (CNA) was observed wearing the same isolation gown while providing care to two residents, one of whom was diagnosed with Clostridium difficile (C-diff), a highly contagious bacterium. The CNA admitted to not changing the gown between caring for the two residents, which was confirmed by the Infection Preventionist and the Director of Staff Development, both acknowledging the potential for cross-contamination. Additionally, the facility lacked dedicated cleaning equipment for the bathroom of the resident with C-diff, as confirmed by the Maintenance Director and housekeeping staff, who were unaware of the requirement for dedicated equipment. Furthermore, the facility's nurse's station counter was found to be in disrepair, with chipped plastic laminate exposing porous wood, making it impossible to properly disinfect. This was confirmed by both a housekeeper and the Infection Preventionist, who acknowledged that the damaged areas could not be adequately disinfected. These observations highlight the facility's failure to adhere to its own policies and procedures regarding infection control, thereby increasing the risk of infection transmission among residents.
Resident Privacy Violations Due to Uninvited Room Entries
Penalty
Summary
The facility failed to protect the privacy rights of five residents when another resident, identified as Resident 20, entered their rooms uninvited. This behavior was confirmed through interviews with the affected residents and staff members. Resident 33, who has severe cognitive deficits, reported that Resident 20 frequently entered her room and rummaged through her belongings. Similarly, Resident 18, who is cognitively intact, expressed discomfort with Resident 20's uninvited visits, which occurred several times a month. The Director of Nursing and other staff members acknowledged that Resident 20 often wandered into other residents' rooms, which was recognized as a residents' rights issue. Interviews with other residents, including Resident 22, Resident 8, and Resident 5, revealed similar experiences of Resident 20 entering their rooms and attempting to go through their belongings. These residents, who were cognitively intact, expressed their dissatisfaction with these intrusions. The facility's policy on resident rights emphasizes the importance of personal privacy, which includes accommodations. Despite this policy, the facility did not effectively prevent Resident 20 from infringing on the privacy of other residents. Staff members, including CNAs, confirmed that Resident 20's behavior was a known issue, yet no effective measures were in place to prevent these privacy violations.
Failure to Provide Adequate Foot Care for a Resident
Penalty
Summary
The facility failed to provide adequate foot care and treatment for one resident, identified as Resident 201, due to a lack of proper assessment and communication. The Licensed Nurse (LN) did not accurately assess the condition of Resident 201's feet upon admission, nor was a care plan developed within the required 48 hours. The resident, who was cognitively intact and capable of making decisions, expressed discomfort and frustration over the lack of communication regarding foot care. Observations revealed that the resident's toenails were long, thick, and discolored, and the skin on the feet was dry, flaky, and discolored, with a cluster of brown growths on the ankle. The Director of Nursing (DON) was not informed of the resident's foot condition, and the physician was not notified, which should have been done according to the facility's policies and procedures. The LN confirmed that no foot care treatments were ordered, and the admission assessment did not accurately describe the resident's foot condition. The failure to assess and document the resident's foot condition and to notify the physician led to the absence of a care plan, which was a requirement as per the facility's policies.
Failure to Supervise Resident Leads to Unsupervised Fall
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 20, who was at risk for wandering and elopement. The resident, who had a history of dementia, agitation, and falls, was found unsupervised in the shower room, resulting in a fall. The shower room door, which was supposed to be locked to prevent access by wandering residents, was left unlocked, allowing the resident to enter and fall. This incident was not isolated, as the resident had previously fallen in the same shower room, prompting the installation of a keypad lock that was not utilized properly. Additionally, the facility did not adhere to the care plan for Resident 20, which required one-to-one supervision every 30 minutes and 15-minute observations as needed. There was no documentation to confirm that these supervision measures were consistently implemented. The Director of Nursing acknowledged the lack of consistent documentation and monitoring, which contributed to the resident's unsupervised wandering and subsequent fall. Furthermore, the resident's wandering behavior was not accurately captured in the Minimum Data Set (MDS) assessment. Despite staff observations and reports of the resident's wandering tendencies, the MDS Nurse incorrectly coded the resident's behavior as not exhibiting wandering. This oversight in documentation and assessment further highlights the facility's failure to provide adequate supervision and care for the resident, increasing the risk of accidents and compromising the resident's safety.
Failure to Arrange Follow-Up Appointment for Resident
Penalty
Summary
The facility failed to provide medically-related social services to a newly admitted resident, identified as Resident 201, who required a follow-up appointment with a vascular surgeon. The resident, who had been admitted with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, was cognitively intact and responsible for their own decisions. The facility's policy required the social worker to perform an initial assessment and document the resident's needs, but this was not done. The discharge documents from the hospital indicated the need for a follow-up appointment with a vascular surgeon within a week, but there was no documentation in the medical record to support that this referral had been made. During interviews and record reviews, it was confirmed that the social services staff was not present at the time of the resident's admission, and the interdisciplinary team (IDT) was responsible for ensuring the appointment was made. However, the IDT failed to ensure the referral was completed. The Director of Nursing confirmed the oversight, acknowledging that the responsibility fell on the IDT in the absence of the social services staff. This failure had the potential to negatively impact the resident's health status, as the necessary follow-up with a vascular surgeon was not arranged.
Deficiency in Dietary Department Cleanliness and Labeling
Penalty
Summary
The facility failed to maintain a clean and orderly environment in the dietary department, as observed during a survey. Specifically, there was an unlabeled storage bin containing a white granulated substance, later identified as sugar, which lacked proper labeling. Additionally, four storage bins containing sugar, chocolate chips, flour, and rice had lids with visible dust, scratches, and adhesive tape residue. These observations were made during an interview with the Dietary Manager, who acknowledged that the bins should have been labeled and clean, as per the facility's policies on ingredient bins and labeling and dating of foods.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure that all resident bedrooms accommodated no more than four residents, as required by regulations. During an initial tour of the facility, it was observed that one room contained five beds, which is a violation of the standard. Despite the room providing a reasonable amount of privacy and adequate storage space, the presence of five residents in a single room did not comply with the regulatory requirements. The Administrator acknowledged the situation and mentioned the continuation of a waiver renewal request.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a working call system was accessible to a resident, identified as Resident 4, which had the potential to delay care and endanger the resident's health and safety. The facility's policy and procedure on call lights required that call lights be placed within reach of residents to allow them to call for assistance. However, during an observation, Resident 4 was found yelling for help because the call light was not within reach. The call light was hanging through the lower portion of the bedrail, below the mattress level, making it inaccessible to the resident. A Certified Nursing Assistant (CNA) confirmed that the resident needed the call light clipped to the blanket to be able to feel or see it. Further observations revealed that the call light cord was located near the foot of the bed, between the mattress and footboard, and hanging down to the ground, which was not within reach of Resident 4. The Director of Staff Development (DSD) and the Director of Nursing (DON) reviewed the resident's care plan, which indicated that the call light should be kept within reach. Despite this, the call light was not positioned appropriately, leading to the deficiency. Resident 4 had a history of chronic obstructive pulmonary disease, multiple fractures, and a history of falling, and was totally dependent on staff for activities of daily living, making the accessibility of the call light crucial for their safety and care.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during an interaction with a staff member. The incident involved a resident who was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). The resident had a history of rheumatoid arthritis, spinal stenosis, adult failure to thrive, gastroenteritis, colitis, and a history of falling. The deficiency occurred when the resident inquired about lost clothing and was met with a rude and disrespectful response from the Maintenance Supervisor (MS). The MS reportedly yelled at the resident, telling them not to ask about the lost pants again and incorrectly stated that the pants were not labeled, despite the resident's assertion that they were. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and addressing grievances promptly. However, during interviews, both the Administrator and the Director of Nursing (DON) confirmed that the resident's rights were violated due to the MS's disrespectful behavior. The incident caused the resident to feel angry and had the potential to result in emotional stress and other negative outcomes. The report highlights the failure of the facility to adhere to its own policies regarding the treatment of residents with dignity and respect.
Failure to Accommodate Resident's Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident when a second bedside table, used for storing art supplies, was removed from her room without her consent. This action was taken by the Maintenance Supervisor, who stated that the table was needed for another resident due to a shortage of bedside tables. The removal of the table led to the resident feeling frustrated and angry, as it violated her right to have her specific needs accommodated. Interviews with the resident, the Administrator, and the Director of Nursing confirmed that the resident required two separate tables, one for eating and another for her art supplies. The Administrator acknowledged that the Maintenance Supervisor should have asked the resident before removing the table and suggested that an alternative could have been provided. The Director of Nursing confirmed that the manner in which the table was removed, without proper communication or explanation, was not appropriate.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to revise and update the care plan for a resident to reflect current individual needs for pain management. The resident, who was admitted with conditions including rheumatoid arthritis, spinal stenosis, and a history of falling, expressed discomfort due to pain in her knees when touched during the night. Despite the resident's request for specific repositioning to avoid pain, the care plan was not updated to include these preferences or the new pain management interventions. The resident's medical record indicated new orders for Methotrexate and Prednisone to manage rheumatoid arthritis, but these were not incorporated into the care plan. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed that the care plan had not been revised to include the new medications and interventions for pain management, leading to the resident's care needs going unrecognized.
Inconsistent Hair Care Assistance for Resident
Penalty
Summary
The facility failed to provide daily hair care for a resident, leading to a deficiency in maintaining the resident's personal hygiene and dignity. The resident, who was admitted with conditions such as Rheumatoid Arthritis and spinal stenosis, required assistance with activities of daily living, including hair care. Despite the facility's policy to provide necessary services for grooming and personal hygiene, the documentation showed inconsistencies in the assistance provided to the resident. Over two months, there were several days where no assistance or inadequate assistance was documented, and the resident's hair care needs were not consistently met. Observations and interviews revealed that the resident's hair was not properly maintained, with matted tangles observed, and the resident expressed dissatisfaction with the hair care provided. The resident mentioned that staff did not have the time to assist daily, and the CNA confirmed the lack of appropriate supplies for hair care. The Director of Nursing acknowledged the resident's need for assistance due to reduced fine motor skills and confirmed the necessity for daily help with hair care.
Failure to Safeguard Resident Dignity and Timely Care
Penalty
Summary
The facility failed to protect the rights of six residents by not safeguarding their dignity and respect. Nursing staff ignored call lights and calls for assistance, and failed to administer pain medications in a timely manner. This led to residents feeling angry, sad, scared, and experiencing increased anxiety and pain. The facility's policies on resident rights, pain management, and medication administration were not adhered to, resulting in these deficiencies. Resident 1 experienced an argument with an LVN over medication administration, where the LVN insisted on giving two teal-colored tablets of Meloxicam, which the resident believed was incorrect. The resident felt angry and frustrated, and reported long delays in call light responses. Resident 2, who is on hospice care, reported a significant delay in receiving pain medication, which exacerbated her anxiety and pain. She described an interaction with the LVN where her request for pain medication was dismissed, leading to further distress. Other residents also reported delays in call light responses and inadequate care. Resident 3 mentioned that call lights sometimes take at least half an hour to be answered. Resident 4 expressed concerns about the night staff's responsiveness, stating it took an hour to have her briefs changed. Resident 5 and his wife reported issues with catheter care during the night shift, and Resident 6 had to assist his roommate due to the lack of staff response. These incidents highlight a pattern of neglect and inadequate care during the night shift, contributing to the residents' dissatisfaction and distress.
Failure to Provide Timely Care for Activities of Daily Living
Penalty
Summary
The facility failed to provide timely care and assistance for activities of daily living, specifically in changing soiled briefs for three residents. Resident 1, who was admitted for heart and kidney failure, anxiety disorder, diabetes, and severe obesity, reported being left in a soiled brief for approximately 12 hours. This occurred because the CNA was unavailable, and the nurses, citing short-staffing, did not return to assist. Resident 4, who required substantial assistance due to diabetes, malnutrition, osteomyelitis, COPD, and a history of stroke, reported not being changed at night unless a specific CNA was on duty. Resident 5, with a foot amputation and infection, also reported not receiving timely assistance, with family members having to request help during visits. The facility's policy on activities of daily living emphasizes the need for care based on comprehensive assessments and resident needs. However, the failure to assign a temporary CNA to specific rooms on a day when staff called off contributed to the neglect of Resident 1. The Director of Staff Development acknowledged the oversight in assigning duties, which may have led to the deficiency. The lack of adequate staffing and communication during shift changes resulted in residents not receiving necessary care, potentially leading to negative health outcomes and loss of dignity.
Disrespectful Behavior by LVN A Violates Resident Rights
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination, as evidenced by the actions of LVN A towards two residents. Resident 1, who was admitted for chronic obstructive lung disease, anxiety, and depression, reported feeling unsafe after LVN A yelled at her for requesting pain medication. LVN A was observed arguing with Resident 1 and administering medication in a disrespectful manner, which was corroborated by CNA C. Resident 1 expressed relief when informed that LVN A would no longer be her nurse. Resident 2, admitted for heart failure and bipolar disorder, also reported feeling unsafe due to LVN A's behavior. The resident recounted an incident where LVN A refused to change her bandage and was rude during a phone call with her son. Resident 2 expressed fear of potential harm from LVN A, who was accused of making racially insensitive remarks. The Director of Nursing confirmed that LVN A had been terminated for arguing with and yelling at Resident 2, which violated the resident's rights. Additional interviews revealed that LVN A had a history of inappropriate behavior towards residents, including demanding respect before administering medication. A local community advocate noted similar complaints about LVN A from other residents. The facility's Employee Handbook emphasizes the importance of treating residents with respect and addressing their needs promptly, which LVN A failed to uphold, leading to the reported deficiencies.
Resident Isolation and Call Light Tampering
Penalty
Summary
A deficiency was identified when a staff member at the facility closed the room door of a resident and silenced the resident's call light, contrary to the facility's policy. The resident, who was admitted for respiratory failure, worsening brain disease, anxiety, and difficulty communicating, had a history of being fearful of confinement due to trauma from a local wildfire disaster. The resident's care plan specifically indicated that the room door should remain open for her comfort. Despite this, the Licensed Vocational Nurse (LVN) involved admitted to closing the door and adjusting the call light system, although she denied disconnecting any wires. Interviews revealed that the LVN had previously threatened to shut the door to quiet the resident and had made changes to the call light system. A Certified Nursing Assistant (CNA) witnessed the LVN's actions and reported that the resident was particularly vulnerable due to her paranoia and fear of being left alone. The Maintenance Director confirmed that the call light system had been tampered with, as two wires were found disconnected, although he did not receive a report from the LVN as claimed. The Director of Nursing (DON) acknowledged the ongoing investigation and confirmed that the LVN had been taken off duty.
Resident Dignity Compromised Due to Unchanged Dressings
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect while eating meals. The resident, who was admitted with multiple medical conditions including sepsis, cellulitis, and severe obesity, was observed with dark, dried, red stains on his shirt, which he identified as blood from unchanged dressings. Despite the resident's request for assistance, no staff had attended to his needs, leading to his frustration. A Certified Nursing Assistant (CNA) reported the issue to a Licensed Nurse (LN), who acknowledged the need to change the resident's dressings but had not yet done so. The Director of Nursing (DON) confirmed that the resident should not have been served meals with soiled dressings and a dirty shirt, acknowledging the situation as a dignity problem. The DON stated that they were unaware of the issue until it was brought to their attention.
Failure to Obtain Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to obtain physician orders for wound care upon the admission of a resident, identified as Resident 2, who was admitted with multiple medical conditions including sepsis, cellulitis, and Bullous Pemphigoid. The admission records were incomplete, lacking necessary wound care orders for open areas on the resident's chest, upper right arm, abdomen, and both lower legs. This oversight was confirmed during a review of the resident's medical records and interviews with facility staff, including the Director of Nursing (DON) and the Medical Director (MD). Interviews with staff revealed that the admission process was not followed, and there was a lack of communication and documentation regarding the resident's condition. The DON confirmed that no wound assessments or measurements were completed, and the MD acknowledged the issue of incomplete admission orders. Staff members, including a Licensed Nurse and a Registered Nurse, admitted to not performing necessary assessments or obtaining verbal reports, citing busyness and oversight as reasons for the lapse in care. This resulted in a delay in addressing the resident's wound care needs.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours for a resident, identified as Resident 2, which is a requirement according to the facility's policy dated February 2023. This policy mandates that a baseline care plan should be created and implemented within 48 hours of a resident's admission to ensure effective and person-centered care. The absence of this care plan was confirmed during a review of Resident 2's medical records, which showed no baseline care plan was developed, despite the resident being admitted with multiple serious health conditions including sepsis, cellulitis, high blood pressure, Bullous Pemphigoid, and severe obesity. Interviews conducted with facility staff further confirmed the deficiency. A Licensed Nurse acknowledged the lack of a baseline care plan in the medical record, which meant staff did not have the necessary information to address Resident 2's specific needs. Additionally, the Director of Nursing confirmed that no admission records, including the baseline care plan, were completed for Resident 2. This oversight had the potential to result in unmet individual needs and negative clinical outcomes for the resident.
Facility Fails to Maintain Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable temperature levels in six resident rooms, leading to discomfort for residents, including one who felt hot and sweaty. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit, but temperatures in the affected rooms ranged from 82.6 to 90.3 degrees Fahrenheit. The issue arose when the HVAC unit stopped working due to an old transformer, and the use of portable air conditioners (P-ACs) caused circuit overloads, tripping the breaker and affecting the oxygen supply for one resident. Resident 1, who had a history of acute myocardial infarction, acute respiratory failure, and chronic kidney disease, was particularly affected. The resident's room temperature was recorded at 85 degrees Fahrenheit, and despite the use of fans and a portable oxygen tank, the resident expressed feeling hot and uncomfortable. The facility was unable to move the resident to a cooler room due to full occupancy, and the DON had to manage the P-AC usage by alternating between rooms to prevent circuit overloads.
Facility Fails to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for six out of 21 resident rooms sampled, potentially affecting 11 residents. The main air conditioning units on the roof were not functioning, and although they were repaired, the room temperatures remained above the facility's policy range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperatures in some rooms reached as high as 84.2 degrees Fahrenheit, which was acknowledged by the Maintenance Director as too hot. Residents expressed discomfort due to the high temperatures, with one resident stating difficulty in breathing and another feeling hot and sweaty. The facility attempted to mitigate the issue by using swamp coolers and portable air conditioners, but these were not effective. The swamp coolers were not used according to the manufacturer's instructions, as there was inadequate airflow in the hallways, and some portable air conditioners could not be used due to electrical issues. Interviews with staff and family members confirmed the ongoing temperature issues, with complaints from residents about the heat. The Maintenance Director noted that the HVAC system had ductwork issues, allowing cold air to escape and hot air to enter, which required further repairs. The facility's failure to maintain a comfortable environment compromised the residents' right to a safe and homelike setting.
Failure to Provide Privacy During Medical Treatment
Penalty
Summary
The facility failed to ensure the right to personal privacy for a resident during medical treatment. The incident involved a resident with multiple diagnoses, including lung disease, diabetes, heart disease, blindness, and bipolar disorder. During an observation, the Maintenance Director and a surveyor were present in the resident's room discussing a maintenance issue when an LVN entered to administer medication. The LVN did not provide privacy for the resident, as she lifted the resident's gown and exposed her bra, abdomen, and briefs without pulling the privacy curtain. The LVN acknowledged during an interview that she failed to provide privacy and admitted it did not cross her mind.
Inaccurate Resident Assessment in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's current status for one of five sampled residents. Specifically, the admission Minimum Data Set (MDS) for a resident dated 3/3/2024 inaccurately indicated that the resident was admitted with an indwelling catheter. This discrepancy was identified during a review of the resident's clinical record and confirmed through observations and interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON). The CNA confirmed that the resident did not have an indwelling catheter and was able to urinate normally, which was further corroborated by the DON who acknowledged the inaccuracy in the MDS assessment. The resident in question had a medical history that included arthritis, end-stage renal disease, dependence on renal dialysis, and muscle weakness. The resident was initially admitted to the facility and later readmitted after a hospital transfer for uncontrolled high blood pressure. Despite these conditions, the MDS inaccurately documented the presence of an indwelling catheter, which was not observed during a physical examination of the resident. This inaccuracy in the resident's assessment had the potential to impact the care and treatments provided to meet the resident's individual needs.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for a resident exhibiting behavior issues, specifically the constant removal of clothes. The resident, who had diagnoses including arthritis, end-stage renal disease, and muscle weakness, was observed sitting on the bed covered only by a blanket and a ripped incontinence brief. The resident expressed confusion about the whereabouts of his clothes and stated he was cold. Staff members acknowledged the resident's behavior but did not have a care plan in place to address it, instead opting to let the resident remain unclothed as he would remove any clothes put on him. During interviews, the Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) confirmed that the resident frequently removed his clothes and that no care plan had been developed to manage this behavior. The ADON admitted that such behavior should have been care planned, and the staff were expected to cover the resident and ensure privacy. However, the care plans reviewed did not include any interventions or strategies to address the resident's specific behavior, leading to a failure in providing necessary care and services to maintain the resident's well-being.
Failure to Provide Timely Urinalysis for Resident with UTI Symptoms
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident exhibiting symptoms of a urinary tract infection (UTI). The resident, who had a history of arthritis, end-stage renal disease, and muscle weakness, was readmitted to the facility after a hospital transfer for uncontrolled high blood pressure. On 3/8/2024, the resident showed signs of a UTI, including dark and foul-smelling urine, vomiting, and bladder pain. The Licensed Nurse (LN) notified the Medical Doctor (MD) and received an order for a urinalysis (UA) and urine culture sensitivity test (C&S). However, the UA and C&S were not ordered or documented in the resident's medical record as required. The Assistant Director of Nursing (ADON) confirmed that the UA was not collected until 3/10/2024, three days after the initial symptoms were reported. The UA report, received on 3/11/2024, confirmed the presence of a UTI. The ADON admitted that there was no documentation explaining why the UA was not collected on 3/8/2024 and acknowledged that staff failed to document whether the UA was collected. This delay in testing and documentation had the potential to delay the resident's treatment and could lead to further complications.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
