Fidelity Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 11210 Lower Azusa Rd., El Monte, California 91731
- CMS Provider Number
- 555088
- Inspections on file
- 30
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fidelity Health Care during CMS and state inspections, most recent first.
A resident with dementia, major depressive disorder, and schizophrenia, assessed as high fall risk with impaired cognition and needing supervision or assistance for transfers and walking, was care planned for close monitoring of location and a safe environment. Despite this, the resident was observed by a family member walking alone in a hallway without staff present, and a CNA did not immediately intervene when notified. Staff interviews revealed that monitoring was based on intermittent checks rather than continuous observation, that one CNA was covering another’s break and could not see all residents, and that staff were not yet fully familiar with the new resident’s needs, contrary to the facility’s fall prevention policy requiring close monitoring of at-risk residents.
A resident with chronic pain syndrome, intact cognition, and independence in daily activities was transferred to a general acute care hospital for pain based on a physician order and documented in progress notes. However, the nurse responsible for the transfer did not complete a Notice of Proposed Transfer/Discharge (NPTD), and the LTC Ombudsman was not notified. During interviews, an LVN, RN, and the DON all acknowledged that facility practice and written policy required completion of an NPTD to inform the resident of the transfer destination and reason, and that this notice should be placed in the medical record and provided to the resident and, if known, a family member or representative.
Two residents with intact cognition and complex medical histories were involved in ongoing verbal and emotional abuse, with one resident repeatedly using derogatory language toward the other. Despite staff awareness and social services intervention, the situation escalated to a physical altercation, resulting in one resident being choked and punched, and sustaining a neck injury. The facility failed to prevent or adequately address the abusive behaviors, leading to a deficiency in protecting residents from abuse.
Two residents with severe cognitive and physical impairments were assisted with eating by CNAs who stood over them rather than sitting at eye level, contrary to facility policy and staff training. This practice failed to honor the residents' right to dignity and proper engagement during mealtime.
Surveyors found that kitchen staff failed to label opened food items with the date opened, did not use pasteurized eggs as required for certain dishes, stored clean dishware and kitchenware uncovered and face up, and did not consistently wear hair restraints in food preparation and dishwashing areas. These actions were not in accordance with the facility's policies and professional standards for food safety.
Staff did not change a resident's nasal cannula for oxygen therapy weekly as required, and personal toiletry items for multiple residents sharing a restroom were found unlabeled and improperly stored, contrary to infection control policies. These lapses were confirmed by staff interviews and policy review.
A resident with severe cognitive impairment and a high risk for falls was found with their call light inaccessible, as it was stuck behind personal belongings. Staff confirmed the resident could not reach the call light, despite care plan and facility policy requiring it to be within reach to ensure timely assistance.
A resident with COPD and diabetes was admitted without a properly completed Advance Directive Acknowledgement (ADA) form. The ADA form lacked documentation of whether the resident had executed an advance directive, was missing a date, and did not have the facility's signature, contrary to facility policy requiring completion within seven days of admission.
A resident with significant care needs was admitted under hospice services, but the facility did not assign a staff member to coordinate with hospice representatives. As a result, scheduled visits by a CHHA could not be verified, and the DON confirmed there was no policy or procedure for assigning responsibility for hospice coordination, leading to uncertainty about whether the resident received necessary hospice care.
A resident with moderately impaired cognition and multiple diagnoses was found to have a bedside electric fan with dust and lint accumulation. An LVN confirmed the fan's unclean condition, and the DON stated that housekeeping is responsible for keeping equipment clean to prevent respiratory issues. Facility policy requires regular housekeeping and maintenance of resident equipment.
The facility failed to follow its policies for screening potential employees for abuse history. The Director of Staff Development did not obtain adequate reference checks for four CNAs, often relying on personal knowledge instead of contacting previous employers. This practice did not comply with the facility's policy, which required at least two reference checks to uncover any past criminal prosecutions or allegations of abuse.
A resident with cognitive impairment was verbally and physically abused by another resident with a history of aggressive behavior. The incident occurred when the assigned CNA left the aggressive resident unattended, contrary to the facility's one-to-one monitoring policy. This lapse in supervision allowed the aggressive resident to scratch and yell at the other resident, resulting in an open cut on the hand.
A facility failed to report an allegation of abuse within the required two-hour timeframe. A resident reported being hit by another resident, but the Social Services Assistant did not inform anyone about the allegation, violating the facility's policy. The reporting failure involved a cognitively intact resident and another resident with schizophrenia. Staff interviews confirmed the importance of timely reporting to prevent further abuse.
The facility failed to submit the Payroll Based Journal (PBJ) staffing data report for the first quarter of 2023, resulting in a one-star staffing rating. Interviews revealed no records of proof indicating the previous Business Office Manager submitted the PBJ data, and the Administrator confirmed the absence of official records. Handwritten notes were found but were not considered official.
The facility failed to ensure call lights were within reach for two residents, leading to potential delays in care and increased fall risk. One resident's bathroom lacked a call light cord, while another's call light was stuck behind a roommate's walker. Both residents had high fall risk and required call lights within reach as per their care plans and facility policy.
The facility failed to supervise two residents adequately, leading to potential safety hazards. One resident with a history of wandering was not provided specific interventions, while another high-risk resident was left unattended multiple times despite requiring continuous one-to-one monitoring.
The facility failed to administer Depakote ER as ordered by splitting the tablet, and did not follow its policy for medication destruction by having an Activity Assistant, supervised by only one licensed nurse, dispose of medications.
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For one resident, a GDR was not completed for Trazodone, and no clinical rationale was documented. For another resident, behaviors related to the use of Zyprexa were not monitored during specific night shifts, contrary to the care plan and facility policy.
The facility failed to discard six glasses of expired milk found in the kitchen refrigerator. The Dietary Supervisor acknowledged that the milk was outdated and should have been removed to prevent food-borne illnesses. The facility's policy indicated that poured beverages should be labeled, dated, and discarded at the end of the day.
The facility failed to follow infection control policies by not ensuring a CNA wore PPE before entering a contact isolation room for a resident with MRSA and by allowing food to be stored in the medication storage room. The CNA entered the resident's room without PPE, and a box of doughnuts was found in the medication room, both actions contrary to the facility's policies.
A resident with COPD, epilepsy, and dementia did not have the privacy curtain closed while a Licensed Vocational Nurse checked the gastrostomy tube site, exposing the resident's abdominal area. This action violated the facility's policy on providing privacy during ADLs and the resident's care plan. The Director of Nursing confirmed the need for the privacy curtain to be closed to maintain the resident's dignity and privacy.
The facility failed to develop a care plan for a resident with dementia, schizophrenia, and anxiety who exhibited wandering behavior by entering other residents' rooms. Despite multiple reports and observations, no care plan addressed the resident's wandering, contrary to facility policy.
The facility failed to conduct an IDT care planning conference for a resident with type 2 diabetes mellitus and anemia within the required timeframe. The DON confirmed that the conference was missed, and an empty form was found in the resident's medical record. This failure had the potential to delay appropriate care and treatment for the resident.
The facility failed to monitor a resident with Parkinson's disease and osteoarthritis during mealtime as required by the care plan, leading to food spillage and potential nutritional deficiencies. Despite observed increased hand tremors, there were no records of assessments or notifications to the medical doctor or occupational therapist.
The facility failed to implement the intervention on a resident's care plan for turning and repositioning every 2 hours, despite the resident's risk for skin breakdown due to impaired mobility and incontinence. Observations showed the resident remained in the same position for extended periods, contrary to the care plan and Resident Positioning Log.
A resident's nasal cannula tubing was observed touching a trash bin, contrary to the facility's Infection Control Policy: Oxygen Use. The resident had COPD and heart failure, and the observation was confirmed by an LVN and the DON, who both acknowledged the risk of infection and cross-contamination.
Failure to Adequately Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a newly admitted resident who was identified as high risk for falls and injuries. The resident was admitted with dementia, major depressive disorder, and schizophrenia, and was care planned on admission as being at high risk for injury, accidents, and falls, with interventions including maintaining a safe, hazard-free environment, keeping the bed in low position with bilateral floor mats, and monitoring the resident’s location as often as possible. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making and a need for partial/moderate assistance with ADLs, as well as supervision or touching assistance for transfers and walking. A Fall Risk Evaluation documented intermittent confusion, balance and gait problems, decreased muscular coordination, use of assistive devices, and three or more predisposing diseases, with a total score of 20, indicating high fall risk. Despite these identified risks and care plan interventions, the resident was observed by a family member walking alone in the hallway without staff supervision, and no staff were present in the immediate area monitoring the resident. The family member reported having to search for staff and, upon informing a CNA that the resident was walking alone, the CNA did not immediately intervene. CNA2 later stated that on the date in question, she was covering another CNA’s break in the dining area and was unable to visually observe all residents, and did not see the resident ambulating in the hallway. RN1 explained that resident monitoring was done through frequent checks and staff awareness rather than continuous observation, and noted that the resident was new and staff might not have been fully familiar with the resident’s needs. The DON stated that staff were expected to follow care plans and provide monitoring, and confirmed that the resident was alert but confused, ambulatory, and required assistance with walking. The facility’s fall prevention policy required close monitoring and observation of at-risk residents for ambulation and transfer attempts with supervision and assistance as needed, which was not implemented for this resident at the time of the incident.
Failure to Complete Transfer/Discharge Notice and Notify Ombudsman for Hospital Transfer
Penalty
Summary
The facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to notify the long-term care Ombudsman when a resident was transferred to a general acute care hospital. The resident had been initially admitted with chronic pain syndrome and, per a history and physical dated several months prior, had the capacity to understand and make decisions. A subsequent MDS indicated the resident had intact cognition and was independent with daily activities and mobility. On the date of transfer, a physician order directed that the resident be transferred to another general acute care hospital via paramedics, and progress notes documented that the resident was transferred for pain. Interviews and record review showed that no NPTD was completed or filed in the resident’s medical record for this transfer. An LVN stated that the nurse who discharged the resident should have completed an NPTD during the transfer process. The DON confirmed that an NPTD could not be found in the resident’s record and stated that the NPTD should have been completed and maintained in the record. An RN explained that the NPTD’s purpose was to inform the resident of the transfer destination and the reason for the transfer, and that it was the facility’s practice to place the NPTD in the medical record as proof of completion. The facility’s policy on Proposed Transfer and Discharge Notice required that written notice be provided to the resident and, if known, a family member or representative, stating the reasons for the transfer or discharge as soon as practicable before it occurred.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental (emotional), and physical abuse, as evidenced by incidents involving two residents. One resident, with a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, was described as having intact cognition and independence in daily activities. This resident was subjected to physical abuse when another resident, who also had intact cognition and a history of intervertebral disc degeneration, osteoarthritis, COPD, and diabetes, became physically aggressive. The aggressive resident stood up from a wheelchair, grabbed the first resident by the neck, choked, and punched them in the stomach. This altercation was witnessed by staff, who observed the physical contact and subsequent injury, including a scratch on the neck that required treatment. The report also documents ongoing verbal and emotional abuse between the two residents. The aggressive resident reported being repeatedly called derogatory names, such as "crack head," by the other resident over the course of a year, despite having asked for the behavior to stop and social services having intervened multiple times. Staff interviews confirmed that the resident who was physically assaulted had a pattern of teasing and using inappropriate language toward other residents, which was recognized as verbal abuse by both nursing and administrative staff. The facility's policy defined such behavior as abuse, including the use of disparaging or derogatory language. Despite documented behavioral issues and ongoing conflict between the two residents, the facility did not prevent the escalation to physical violence or adequately protect the residents from continued verbal and emotional abuse. Staff were aware of the problematic interactions, and interventions by social services had occurred, but the abusive behaviors persisted, culminating in a physical altercation that resulted in injury. The facility's failure to prevent these incidents constituted a deficiency in protecting residents' rights to be free from all forms of abuse.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to treat two residents with dignity during mealtime assistance. For one resident with Parkinson's disease, dementia, and severely impaired cognitive skills, a CNA was observed feeding the resident while standing over the bed, with the resident's head at the CNA's waist level. The resident was in a high Fowler's position and required assistance with meals as documented in the care plan. Facility staff, including another CNA and the Director of Nursing (DON), confirmed that proper feeding technique requires staff to be seated at eye level with the resident to ensure comfort and engagement. Facility policy also specifies that feeding should be conducted in a patient, respectful, and dignified manner. A second resident, diagnosed with dementia, hemiplegia, and hemiparesis, was also observed being fed by a CNA who was standing at the bedside. This resident had severely impaired cognition and required partial to full assistance with eating and other activities of daily living. Interviews with staff and review of facility policy confirmed that staff should sit at eye level with residents during feeding to promote engagement and maintain a calm, pleasant dining environment. The observed actions were inconsistent with both facility policy and staff training, resulting in a failure to honor the residents' right to dignity during mealtime.
Failure to Follow Safe Food Handling, Storage, and Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen to adhere to safe food handling and storage practices as outlined in the facility's own policies and professional standards. Specifically, opened boxes of frozen pineapple sherbet and strawberry ice cream in Freezer 2 were marked only with a received date and not labeled with an opened date, contrary to posted signage and policy requirements. In the walk-in refrigerator, a 36-count of white eggs was stored on top of a box of 150 eggs with no indication that the eggs were pasteurized, despite the facility's policy requiring the use of pasteurized eggs for dishes requiring raw or undercooked eggs. The Dietary Supervisor confirmed that pasteurized eggs should be used to prevent foodborne illness, especially given the vulnerability of the elderly population served. Additionally, clean dishware and kitchenware were stored face up and uncovered on shelves and utility carts, rather than being stored upside down or covered as required to prevent contamination. Staff were also observed in the kitchen and dishwashing areas without wearing required hair restraints, with one staff member handling her hair while in the dishwashing station. The Dietary Supervisor acknowledged that hair restraints are mandatory upon entering the kitchen and that the facility provides hairnets at the kitchen door. Review of facility policies confirmed the requirements for labeling opened food, using pasteurized eggs, storing kitchenware in a sanitary manner, and mandatory use of hair restraints in food service areas.
Failure to Follow Infection Control Protocols for Oxygen Equipment and Personal Toiletries
Penalty
Summary
The facility failed to implement infection control guidelines in two key areas. First, a resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was observed using a nasal cannula (NC) for oxygen therapy that had not been changed weekly as required. The NC bag was dated nearly a month prior to the observation, and both the Licensed Vocational Nurse and the Infection Preventionist Nurse confirmed that the NC should be changed weekly to prevent bacterial accumulation, in accordance with facility policy. The resident's medical records indicated an active order for oxygen via NC as needed for respiratory symptoms and comfort. Second, the facility did not ensure that personal toiletry items were properly labeled and stored for several residents sharing a restroom. During an observation, an unlabeled, opened bottle of moisturizing shampoo and body wash was found on the window sill of a shared restroom accessible by six residents with varying degrees of cognitive impairment and assistance needs. The Certified Nursing Assistant and Infection Preventionist Nurse both stated that personal toiletries should be labeled and stored at the resident's bedside or in their drawer to prevent cross-contamination, as outlined in the facility's policies on personal hygiene items and infection control. These failures were identified through observation, interviews with staff, and review of facility policies and resident records. The deficiencies had the potential to contribute to the spread of infection within the facility, as personal care items were not managed according to established infection prevention protocols.
Call Light Not Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the call light was found stuck behind the resident's personal belongings, making it inaccessible. Certified Nurse Assistant 3 confirmed that the resident would not be able to find or reach the call light in its current position. The resident was assessed as high risk for falls and had severely impaired cognition, requiring significant assistance with daily activities. The resident's care plan specifically directed staff to keep the call light within reach and to answer it promptly, given the resident's history of attempting to get out of bed unassisted. The Director of Nursing also stated that the call light should be placed next to the resident's strong arm and hand to allow the resident to call for assistance. Facility policy further required that call lights be within reach when residents are in their rooms. These requirements were not met at the time of the surveyor's observation.
Failure to Complete Advance Directive Acknowledgement on Admission
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for one resident. Upon admission, the required Advance Directive Acknowledgement (ADA) form for this resident was not properly completed. Specifically, the ADA form did not indicate whether the resident had executed an advance directive, was missing a date for the resident's signature, and lacked the facility's signature. The facility's policy requires that ADA forms be completed within seven days of admission by the Social Services Director or designee. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes mellitus, and was assessed as having intact cognition and requiring some assistance with activities of daily living. During an interview, the Social Service Director confirmed that the ADA form was incomplete and stated that the resident had not executed an advance directive. The incomplete documentation meant that staff would not have clear information about the resident's care and treatment preferences in the event of an emergency.
Failure to Designate Staff for Hospice Coordination
Penalty
Summary
The facility failed to designate a member of its Interdisciplinary Team (IDT) to coordinate care with hospice representatives for a resident who was receiving hospice services. The resident, who had diagnoses including adult failure to thrive and rhabdomyolysis, required substantial to maximal assistance for personal hygiene and dressing, and had unclear speech with limited ability to communicate. The resident was readmitted to the facility under hospice care, and hospice visitation schedules indicated that a Certified Home Health Aide (CHHA) was supposed to visit on specific dates. However, a review of the hospice staff sign-in logs showed no evidence that the CHHA signed in or provided care on the scheduled dates. The Director of Nursing (DON) confirmed that there was no designated staff member responsible for coordinating with hospice staff or monitoring their scheduled visits. Additionally, the facility lacked a policy or procedure for assigning a staff member to coordinate hospice services, resulting in an inability to verify whether the resident received the necessary hospice care as scheduled.
Unsanitary Electric Fan in Resident Room
Penalty
Summary
A deficiency was identified when an electric fan in a resident's room was found to be in an unsanitary condition. During an observation and interview, a black standing fan at the resident's bedside was noted to have dust on the blades and lint on the cover. The Licensed Vocational Nurse present acknowledged that the fan was not clean and stated that the resident could potentially inhale the dust and lint. The resident in question had moderately impaired cognition and required assistance with showering and personal hygiene, as documented in their Minimum Data Set. The resident's medical history included hypertension, anxiety, and osteoarthritis. Further interviews revealed that the Director of Nursing expected housekeeping staff to keep all equipment in residents' rooms clean and in good working condition to prevent respiratory-related illnesses. A review of the facility's Homelike Environment Policy indicated that regular housekeeping and maintenance should be provided while preserving residents' personal touches. The failure to maintain the fan in a clean and sanitary condition constituted a deficiency in ensuring a safe, clean, and comfortable environment for the resident.
Failure to Implement Employee Screening Policies
Penalty
Summary
The facility failed to implement its written policies and procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of property. Specifically, the facility did not obtain information from previous employers for four sampled Certified Nursing Assistants (CNAs). The Director of Staff Development (DSD) was responsible for conducting reference checks but only contacted the most recent employer and sometimes used personal knowledge as a second reference. This practice did not align with the facility's policy, which required at least two reference checks from current and previous employers. During interviews and record reviews, it was revealed that the DSD often did not document attempts to contact references, making it difficult to verify the thoroughness of the screening process. The facility's policy, titled Patient Abuse Prevention, required informing previous employers of the intention to uncover any past criminal prosecutions or allegations of abuse. The Administrator confirmed that the DSD was responsible for this screening process and acknowledged the failure to adhere to the policy, which had the potential to expose residents to abuse, neglect, exploitation, or misappropriation of property.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect Resident 1 from verbal and physical abuse by Resident 2, as per the facility's Abuse Prevention policy. Resident 1, who was readmitted to the facility with multiple diagnoses including osteoarthritis and anxiety, was involved in an altercation with Resident 2. Resident 1, who had moderate cognitive impairment and required assistance with daily activities, was scratched on the right hand by Resident 2, resulting in an open cut. The incident occurred after a verbal disagreement over the room light, and later, Resident 2 approached Resident 1, yelled, and hit them on the hand. Resident 2, who was diagnosed with schizophrenia and depression, had a history of aggressive behavior and was under orders for one-to-one monitoring due to these tendencies. However, on the day of the incident, the assigned CNA left Resident 2 unattended to use the restroom without informing another staff member, leaving Resident 2 unsupervised. This lapse in supervision allowed Resident 2 to engage in the altercation with Resident 1, which was not immediately addressed by staff. The facility's policies on Abuse Prevention and One-on-One Monitoring were not adhered to, as continuous supervision was not maintained for Resident 2. The Director of Nursing acknowledged that the CNA should have informed another staff member before leaving Resident 2 unattended. The lack of adherence to the monitoring policy and the absence of staff during the incident contributed to the failure to prevent the abuse of Resident 1 by Resident 2.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as per their policy and procedure titled 'Abuse Prevention.' On March 6, 2025, a resident reported to the Social Services Assistant (SSA) that another resident had hit them. Despite the report, the SSA did not inform anyone about the allegation, which was a violation of the facility's policy and legal requirements. The SSA acknowledged the importance of reporting such incidents to prevent further abuse and to determine the facts of the situation. The deficiency involved two residents: one who reported being hit and another who was accused of hitting. The resident who reported the incident was cognitively intact and capable of making decisions, while the accused resident had a diagnosis of schizophrenia and was moderately cognitively impaired. Interviews with various staff members, including the Director of Staff Development and the Administrator, confirmed that all staff were mandated reporters and that any allegations of abuse should be reported within two hours to the appropriate authorities, including the Department of Health and the LTC Ombudsman.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2023. During a review of the facility's Certification and Survey Provider Enhanced Reports (CASPER) 1705D, it was found that the PBJ Staffing Data Report indicated a failure to submit data, resulting in a one-star staffing rating. Interviews with the Payroll Human Resources (PHR) and the Business Office Manager (BOM) revealed that there were no records of proof indicating the previous BOM submitted the PBJ data for the specified period. Handwritten notes were found, but no official records of data submission to CMS were available. The Administrator (ADM) confirmed that the facility had no records of proof of submission of PBJ data and no records that CMS received them for the first quarter of 2023. The ADM acknowledged that handwritten notes on PBJ were not official and emphasized the importance of submitting accurate PBJ reports to CMS before the deadline to maintain compliance with federal regulations. A review of the facility's Policy and Procedure (P&P) on PBJ Reporting Policy indicated that the human resources department is responsible for overseeing PBJ reporting and ensuring compliance with federal regulations. The failure to submit the PBJ report on time could affect the facility's star rating and indicate a staffing concern for the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to potential delays in care and increased risk of falls. Resident 31's bathroom did not have a call light cord, which was confirmed through observations and interviews with the resident, an LVN, and the DON. The resident's care plan indicated a high risk for falls and required the call light to be within reach, but this was not adhered to. The facility's policy also mandated that call lights be within reach, but this was not followed in Resident 31's case. Similarly, Resident 7's call light was not within reach as it was stuck behind the roommate's walker. This was observed and confirmed by an LVN and the DON. Resident 7's care plan also indicated a high risk for falls and required the call light to be within reach. The facility's policy on call lights was not followed, putting Resident 7 at risk. Both residents had significant medical histories that made the availability of call lights crucial for their safety and timely care.
Failure to Supervise Residents Adequately
Penalty
Summary
The facility failed to supervise two residents adequately, leading to potential safety hazards. Resident 67, who had a history of wandering due to dementia and schizophrenia, was observed wandering into other residents' rooms in search of cigarettes. Despite having a Wanderguard and a care plan indicating frequent monitoring, the facility did not implement specific interventions to address this behavior. Multiple residents reported feeling uneasy and witnessing Resident 67's wandering behavior, which was not adequately addressed by the staff or reflected in the care plan. Resident 70, assessed as high risk for falls, was not provided continuous one-to-one monitoring as required by their care plan. Observations revealed that Resident 70 was left unattended multiple times, despite the assigned CNAs acknowledging the need for continuous supervision. The facility's monitoring logs confirmed that the assigned staff failed to maintain continuous visual supervision, leaving Resident 70 at risk of falling again. Interviews with staff, including the Director of Nursing and Social Services Director, confirmed the lapses in supervision and the inadequacy of the existing care plans. The facility's policies on supervision and one-on-one monitoring were not followed, leading to potential safety risks for both residents. The staff acknowledged the need for more effective interventions and continuous monitoring to ensure resident safety.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered and disposed of according to its policy and procedure. Specifically, a Licensed Vocational Nurse (LVN) split a Depakote Extended Release (ER) 500 mg tablet in half and administered it to a resident with a seizure disorder, contrary to the physician's order and the medication's intended use. The resident's care plan indicated that medications should be administered as ordered, and the facility's policy stated that extended-release medications should not be altered. The LVN acknowledged that there was no physician order to break the Depakote ER in half and that doing so could affect the medication's efficacy. The Director of Nursing (DON) and the facility's Pharmacy Consultant confirmed that Depakote ER should not be split, as it would modify the medication's release and effectiveness. Additionally, the facility did not follow its policy for the destruction of discontinued medications. The policy required that two licensed nurses witness the destruction of medications, but an Activity Assistant (AA) was tasked with this responsibility, supervised by only one licensed nurse. The DON admitted to instructing the AA to help with medication disposal, which was against the facility's policy. The AA confirmed that only one licensed nurse was present during the medication destruction process, contrary to the policy that required two licensed witnesses.
Failure to Monitor and Provide Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For Resident 67, a GDR was not completed for the use of Trazodone 100 mg, and no clinical rationale was documented. Despite consistent sleep patterns, the Nurse Practitioner (NP) did not attempt a GDR, and the Director of Nursing (DON) acknowledged that the GDR request was missed. The Psychiatric Progress Note and the Note to the Attending Physician/Prescriber did not provide specific benefits for the continued use of the medication, and the Pharmacist Consultant emphasized the importance of documenting failed GDR attempts and following up accordingly. For Resident 7, the facility did not monitor behaviors related to the use of Zyprexa for schizophrenia during specific night shifts. The care plan required staff to evaluate the effectiveness of Zyprexa and monitor paranoid delusions, but there was no documented monitoring for the specified dates. Both the Registered Nurse (RN) and the DON confirmed the lack of monitoring, which was necessary to determine the medication's effectiveness. The facility's policy indicated that all residents receiving psychotropic medications should be monitored for effectiveness and adverse reactions, but this was not followed in Resident 7's case. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the use of psychotropic medications. The lack of proper documentation and monitoring for GDR and behavior assessments could lead to the continued use of unnecessary medications, posing potential risks to the residents involved.
Expired Milk Not Discarded
Penalty
Summary
The facility failed to follow required food sanitation and handling practices by not discarding six glasses of expired milk found in the kitchen refrigerator. During an initial kitchen tour with the Dietary Supervisor (DS), it was observed that the milk was outdated and should not have been left inside the refrigerator past the expiration date. The DS acknowledged that consuming expired milk could cause food-borne illnesses such as diarrhea and vomiting and stated that expired food should be removed and discarded by the end of the expiry date. A review of the facility's Policy and Procedure (P&P) on Food Receiving and Storage of Cold Foods indicated that poured beverages like milk should be labeled, dated, and discarded at the end of the day.
Infection Control Policy Violations
Penalty
Summary
The facility failed to follow infection control policy and procedures by not ensuring that a Certified Nursing Assistant (CNA) wore the required personal protective equipment (PPE) before entering a contact isolation room for a resident diagnosed with MRSA. The CNA entered the resident's room, picked up the resident's call light from the floor, and placed it back on the bed linen without wearing gloves or other PPE. The resident's care plan indicated the need for isolation precautions, and the facility's policy required staff to wear appropriate PPE when entering the room of a resident with a contagious infection. The Infection Preventionist Nurse confirmed that staff needed to wear PPE to prevent the transmission of infection and protect other residents. Additionally, the facility failed to ensure that food was not stored in the medication storage room. During an observation, a box of doughnuts was found on top of the medication cabinet. The Registered Nurse and Director of Nursing both stated that food should not be stored in the medication room and should be kept in the employee break room. The facility's policy on food storage indicated that food should be stored properly to maintain safety and prevent contamination. The Infection Prevention Nurse also confirmed that food should be stored in the employee lounge to prevent the spread of infection.
Failure to Ensure Privacy During G-Tube Check
Penalty
Summary
The facility failed to ensure privacy for Resident 42 while checking the gastrostomy tube (G-tube) site. During an observation, Licensed Vocational Nurse 1 (LVN 1) opened the resident's gown and checked the G-tube site without closing the privacy curtain, thereby exposing the resident's abdominal area. This action was contrary to the facility's policy on providing privacy during activities of daily living (ADL) and the resident's care plan, which required nursing staff to provide privacy at all times. LVN 1 acknowledged that the privacy curtain should have been closed to maintain the resident's dignity and privacy. Resident 42, who was admitted to the facility on 8/28/2017 and readmitted with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, and a need for attention to the gastrostomy, did not have the capacity to understand and make decisions. The resident's care plan indicated muscular weakness and dementia, requiring maximum assistance with various ADLs. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's privacy and dignity. The facility's policy emphasized treating residents with dignity, respect, and sensitivity, and required the use of closed doors, curtains, or partitions to provide privacy during ADLs.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a care plan for Resident 67, who exhibited wandering behavior by entering other residents' rooms. Resident 67, diagnosed with dementia, schizophrenia, and anxiety, was observed wandering alone in the hallways and entering other residents' rooms. Multiple residents reported that Resident 67 frequently entered their rooms, sometimes attempting to take items such as cigarettes. Despite these reports and observations, there was no care plan addressing Resident 67's wandering behavior, which was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The facility's policy required care plans to be updated based on specific behaviors, but this was not done for Resident 67's wandering behavior. Interviews with staff, including the Social Services Director (SSD) and the DON, revealed that the facility's usual response to wandering behavior was to redirect the resident to activities and notify the family. However, this approach was not documented in a care plan for Resident 67. The SSD and DON acknowledged that the care plan should have been updated to include specific interventions for Resident 67's wandering behavior. The facility's policy on care plan revision emphasized the need for measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Conduct Timely IDT Care Planning Conference
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) care planning conference for Resident 184 in accordance with its Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. Resident 184 was admitted to the facility with diagnoses including type 2 diabetes mellitus and anemia. The Minimum Data Set (MDS) indicated that Resident 184 had clear speech and the ability to understand others and make self-understood. However, during an interview and record review, the Director of Nursing (DON) confirmed that Resident 184 did not have an IDT care planning conference within the required timeframe. An empty form titled Admission / 72 hours IDT Conference was found in Resident 184's medical record, indicating that the conference was not conducted as required. The DON stated that the IDT conference should have been completed within 72 hours after admission, but it was missed and delayed for Resident 184. The facility's P&P indicated that a comprehensive care plan should be developed within seven days of the resident assessment, involving multiple departments and the resident or responsible party to create a person-centered plan of care. The failure to conduct the IDT care planning conference in a timely manner had the potential to prevent Resident 184 from receiving appropriate care and treatment promptly.
Failure to Monitor Resident During Mealtime
Penalty
Summary
The facility failed to ensure that Resident 5 was assessed and monitored during mealtime as indicated in the resident's care plan. Resident 5, who has diagnoses including Parkinson's disease and osteoarthritis, was observed eating alone in her room with her right hand shaking, causing food to spill on the tray. This lack of supervision during mealtime was contrary to the care plan interventions, which specified that the resident should be monitored during meals due to the potential for injury from tremors and involuntary movements. Additionally, the care plan indicated the need to observe the resident for a decline in mobility and function and to notify the medical doctor promptly, which was not done in this case. Interviews with the Dietary Supervisor and the Registered Nurse Supervisor revealed that Resident 5's increased hand tremors had been noticed, but there were no records indicating that the resident was assessed and monitored during mealtime or that the medical doctor or occupational therapist were notified of the increased tremors. The Director of Nursing confirmed that mobility assessments are typically done annually, quarterly, and as needed, but there was no documentation to support that these assessments were conducted for Resident 5. The facility's policy on Assistance with Meals, which requires residents to receive meal assistance in a manner that meets their individual needs, was not followed in this instance.
Failure to Implement Repositioning Interventions
Penalty
Summary
The facility failed to implement the intervention on the resident's care plan for turning and repositioning every 2 hours for Resident 23, who was at risk for skin breakdown due to impaired mobility and incontinence. Despite the care plan and the Resident Positioning Log indicating that Resident 23 should be turned and repositioned every 2 hours, multiple observations on 4/24/2024 showed that Resident 23 remained in the same position for extended periods, specifically on her left side facing the door from 9:07 am to 2:08 pm, before being repositioned on her back at 2:52 pm. Interviews with CNA 3 and the DON confirmed the importance of turning and repositioning every 2 hours to prevent skin breakdown for residents with poor mobility. The DON acknowledged that Resident 23 needed to be turned and repositioned at least every 2 hours. However, the observations and the review of the Resident Positioning Log indicated that this intervention was not consistently implemented, placing Resident 23 at risk for developing skin breakdown.
Failure to Maintain Clean Oxygen Tubing
Penalty
Summary
The facility failed to ensure that a resident's nasal cannula tubing was not touching the trash bin, which is against professional standards of practice and the facility's own Infection Control Policy: Oxygen Use. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure, was observed with their oxygen tubing in contact with the trash bin while eating breakfast. This observation was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the tubing should not be touching the trash bin due to the risk of infection and contamination. The Director of Nurses (DON) also confirmed that oxygen tubing should not be in contact with the trash bin to prevent infection and cross-contamination. The facility's policy, dated April 2018, states that oxygen equipment should be inspected regularly for signs of damage, wear, or contamination, and that any damaged or contaminated equipment should be replaced or repaired promptly. The failure to adhere to this policy had the potential to increase the risk of infection for the resident.
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.
