Fowler Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fowler, California.
- Location
- 8448 East Adams Avenue, Fowler, California 93625
- CMS Provider Number
- 555918
- Inspections on file
- 21
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fowler Care Center during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitation standards, affecting all 44 residents. Expired honey mustard packets and unlabeled food items were found, and a dietary aide's cell phone was improperly placed on a spice rack, violating infection control policies. Additionally, the ice machine's water pump had black spots, posing a contamination risk. These deficiencies indicate a failure to ensure a safe and sanitary environment for food preparation and storage.
The facility failed to maintain a safe and homelike environment, with five resident rooms having malfunctioning screen doors and three resident doors not functioning properly. A resident reported issues with his screen and room doors, which were not addressed. Staff, including CNAs and the Maintenance Supervisor, were unaware of the issues, and the Administrator emphasized the importance of maintaining doors for safety. The facility's policies on maintenance were not effectively implemented, leading to these deficiencies.
The facility failed to maintain resident privacy during medication administration and blood sugar checks, as observed with several residents. LVNs administered medications and performed procedures without closing privacy curtains or doors, compromising resident dignity. Facility policies emphasize the importance of privacy, which was not followed in these instances.
The facility failed to develop comprehensive care plans for several residents, including those requiring Enhanced Barrier Precautions and those on anticoagulant medication. This oversight led to unmet needs and potential risks, as care plans are essential for directing staff in meeting residents' needs. The Infection Preventionist and Director of Nursing acknowledged the importance of timely and resident-centered care plans.
A facility failed to maintain professional standards of care for several residents. A resident with a physician's order for a low air loss mattress was found with the device unplugged, risking pressure ulcer development. Additionally, the Infection Preventionist did not obtain necessary physician's orders or perform wound assessments for residents requiring Enhanced Barrier Precautions, increasing the risk of infection transmission.
A facility's medication error rate exceeded the acceptable threshold, with errors involving an LVN administering incorrect dosages and not following administration instructions. One resident received an underdose of lactulose, while another was given metformin without food, contrary to orders. These errors could impact the residents' health, given their medical histories.
The facility failed to maintain an effective infection control program when staff did not provide hand hygiene to residents before meals, increasing the risk of cross-contamination. Interviews with CNAs, an Activities Assistant, and the DON confirmed the oversight, despite the facility's policy requiring hand hygiene. This deficiency was observed during a meal service where residents participated in activities without subsequent hand hygiene.
A resident with no cognitive deficits was not allowed to smoke since admission, despite expressing a desire to do so against medical advice. The facility failed to identify her as a smoker during admission, and no Resident Safe Smoking Assessment was completed. Staff interviews confirmed awareness of her rights, but her choice was not implemented, violating her rights and impacting her quality of life.
A resident with hemiplegia, hemiparesis, dementia, and muscle weakness was found with their low air loss mattress turned off and unplugged, contrary to their care plan. The mattress, essential for preventing skin breakdown, was supposed to be on at all times. Facility staff, including a CNA, LVN, and the DON, acknowledged the oversight, which violated the facility's policy for a safe and homelike environment.
The Infection Preventionist (IP) at a facility failed to manage residents requiring Enhanced Barrier Precaution (EBP) effectively, lacking necessary competencies and skills. The IP did not place physician's orders for residents on EBP, initiate care plans within 24 hours, or document wound assessments, increasing infection risk. The Director of Nursing confirmed the IP's responsibility in identifying EBP needs and ensuring precautions were communicated.
A resident with hemiplegia and other health conditions was not provided with a required scoop plate for her meal, as indicated on her meal ticket. The facility's only scoop plate had broken, and a replacement had not yet arrived. Staff confirmed the importance of the scoop plate for the resident's ability to eat with limited assistance, highlighting a deficiency in meeting her individualized care needs.
The facility did not meet the required minimum square footage per resident in 10 rooms, affecting multiple residents. Despite this, residents had privacy, adequate storage, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect resident health and safety.
A resident with a history of elopement and cognitive impairment managed to leave the facility unsupervised, despite protocols for perimeter checks every 15 minutes. The resident used a kitchen meal cart to climb over the fence and was found a mile and a half away. Staff interviews revealed that the assigned hospitality aide was not performing the required perimeter checks at the time of the incident.
A resident with a history of traumatic brain injury and psychosis eloped from a facility by using a barrel to climb over an 8-foot fence. The resident was found by a motorist half a mile away. The facility's inadequate supervision and security measures, including unalarmed doors and unsupervised outdoor areas, contributed to the incident.
A resident with a traumatic brain injury and mild cognitive impairment eloped from the facility due to inadequate supervision. Despite being identified as an elopement risk, the resident was not on one-to-one monitoring and was found walking on the road by an off-duty CNA. The facility's gate was functioning properly, but the resident's unsupervised departure highlights a lapse in supervision.
A resident with traumatic brain injury and dementia, identified as an elopement risk, left the facility unsupervised and was missing for over eight hours. The resident likely exited with visitors when the gate was unlocked, despite the facility's locked perimeter and policies requiring supervision for at-risk residents.
The facility failed to adhere to food safety and sanitation standards, including unclean windowsills, sediment build-up on the dishwashing machine, lack of air gaps in the food preparation sink and ice machine, inadequate dishwashing temperatures, soiled oven mitts, and improperly labeled food in the resident's refrigerator. These deficiencies were confirmed by the RD, CDM, and POS, indicating non-compliance with the facility's policies.
The facility failed to provide a clean and safe environment, with observations revealing damaged and unsanitary flooring in the kitchen dry storage and common areas. Interviews with staff confirmed the difficulty in cleaning and the potential for contamination and falls. The facility's policies on sanitation and maintaining a safe environment were not upheld.
The facility failed to follow their grievance policy by not ensuring residents could submit grievances anonymously. Residents had to ask staff for grievance forms, which were kept in locked drawers or behind the nurses' station, contradicting the facility's policy. This could deter residents from voicing their concerns and negatively affect their psychosocial well-being.
The facility failed to maintain accurate medical records for four residents, resulting in incomplete Physician Orders for Life-Sustaining Treatment (POLST) forms. Missing information included physician details, preparer information, and additional contact details. Discrepancies were also found in the code status of one resident between the electronic medical record and the paper chart.
A resident was not offered water to rinse her mouth after using an aerosol oral inhaler, contrary to the physician's order. This oversight by the Director of Staff Development increased the risk of oral thrush for the resident, who had moderate cognitive impairment.
The facility failed to label one inhaler and one nasal spray medication with resident identifiers and expiration dates, as observed by the Infection Preventionist. The Director of Nursing confirmed that this oversight placed residents at risk for medication errors and receiving less effective medications.
The facility failed to monitor and maintain a resident's oxygen concentrator, resulting in the equipment being dusty and the filter not being clean. Staff were unsure when the equipment was last cleaned, and the resident expected the concentrator to be properly maintained. The DON acknowledged the need to follow manufacturer instructions but did not provide the maintenance log.
The facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms. Despite this, residents had a reasonable amount of privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms.
The facility failed to maintain a functioning call light system for 17 residents' beds, leading to residents being unable to request assistance from nursing staff. The issue was identified during inspections and interviews, revealing a lack of communication and oversight among staff, and placing residents' health and safety at risk.
A CNA worked for five days without an active certification due to lapses in monitoring by the DON and DSD. The facility did not follow its policy to ensure CNAs' certificates were active, leading to the CNA providing care without proper certification.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food and ice were stored, prepared, and served safely in accordance with professional standards for food service safety, affecting all 44 residents. During an observation, expired honey mustard packets were found in the kitchen dry storage room, and the Certified Dietary Manager (CDM) acknowledged that these should have been removed. Additionally, both the honey mustard packets and frozen sausage pizza toppings lacked proper labeling, including receive, open, and use by dates, which the CDM admitted was a responsibility of the kitchen staff to maintain. Further observations revealed a dietary aide's personal cell phone on the kitchen spice preparation rack, which was confirmed by both the CDM and the dietary aide as a violation of the facility's infection control policies. The presence of personal items in the kitchen was identified as a potential risk for cross-contamination and foodborne illness. The Registered Dietician (RD) and the Administrator (ADM) both expressed expectations that personal belongings should not be in the kitchen, aligning with the facility's policies. Additionally, the ice machine's water pump was found to have black spots, which were confirmed by the CDM and Maintenance Supervisor (MS) as a contamination risk. The RD and ADM both expected the ice machine to be clean and free from such substances, as per the facility's infection control policies. The presence of these deficiencies indicates a failure in maintaining a safe and sanitary environment for food preparation and storage, potentially putting residents at risk for foodborne illnesses.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, comfortable, and homelike environment for residents, staff, and the public. During an initial tour, it was observed that five out of six resident rooms had screen doors that were not functioning properly, and one room was missing a screen door entirely. Additionally, three out of sixteen resident doors were not functioning properly, which could potentially violate residents' rights to privacy and increase the risk of accidents. Resident 42, who was admitted with muscle weakness and multiple fractures, reported issues with his screen door and room door, which were not addressed by the facility. Interviews with staff, including Certified Nurse Aides (CNAs) and the Maintenance Supervisor (MS), revealed a lack of awareness and communication regarding the malfunctioning doors. CNA 5 and CNA 6 were not aware of the issues with the screen doors and room doors, and they reported building issues to the MS either in person or through the electronic reporting system, TELS. The MS, upon inspection, confirmed the malfunctioning screen doors and was aware of some door issues due to recent floor installations but had not addressed them yet. The Administrator (ADM) was also unaware of the door issues and emphasized the importance of maintaining doors in good working condition for safety. The facility's policy and procedure on providing a safe and homelike environment, as well as the Maintenance Director's job description, highlighted the need for regular maintenance and prompt reporting of issues. However, these procedures were not effectively implemented, leading to the observed deficiencies.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during medication administration and blood sugar checks. Licensed Vocational Nurses (LVNs) 1 and 2 administered medications to several residents without closing the privacy curtains or doors, compromising the residents' privacy. This occurred for five of six sampled residents, including those with no cognitive deficits and one with moderate cognitive impairment. During observations, LVN 1 administered medications to residents in shared rooms without providing privacy, acknowledging the oversight as a dignity issue. Similarly, LVN 2 checked a resident's blood sugar level without closing the privacy curtain or door, allowing another resident to observe the procedure. Both LVNs admitted they should have ensured privacy during these care activities. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the facility's practice is to provide privacy during such procedures, recognizing it as a matter of resident rights and dignity. The facility's policies on resident rights and medication administration emphasize the importance of maintaining resident privacy, which was not adhered to in these instances.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet needs and potential risks. For six residents, there were no care plans for Enhanced Barrier Precautions (EBP), an infection control strategy involving the use of gowns and gloves during high-contact care. This oversight was identified during a review of the residents' clinical records and confirmed by the Infection Preventionist (IP), who acknowledged that care plans should have been initiated immediately upon placing residents on EBP. The Director of Nursing (DON) and other staff members reiterated that care plans are essential for directing staff in meeting residents' needs. Another resident's care plan for EBP was not initiated in a timely manner, despite the presence of a surgical site that increased the risk of infection. The IP admitted that the care plan was created only after the survey, which was not within the appropriate timeframe. The DON emphasized that care plans should be completed promptly to ensure resident-centered care. Additionally, a resident's activities care plan lacked a person-centered approach, failing to reflect the resident's interests and preferences, which are crucial for their mental, emotional, and physical health. Furthermore, a resident with impaired cognitive function and dementia did not have a timely care plan, potentially increasing the risk of cognitive decline. The facility's policy required care plans to be developed within 14 days, but this was not adhered to. Lastly, a resident on anticoagulant medication did not have a care plan addressing the use of the medication, which is necessary for monitoring potential side effects and ensuring the resident's safety. The DON confirmed that all care plans should reflect residents' needs and active orders to ensure appropriate monitoring and precautions.
Failure to Maintain Professional Standards and Infection Control
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for eight of nine sampled residents. Resident 12, who had a physician's order for a low air loss mattress to prevent pressure ulcers, was found with the mattress unplugged and turned off. This oversight was confirmed by a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), both of whom acknowledged the importance of keeping the mattress operational to prevent skin breakdown. The Director of Nursing (DON) also confirmed that the mattress should have been on at all times, and its failure to operate put Resident 12 at risk of developing pressure ulcers. Additionally, the facility did not adhere to infection control measures for residents requiring Enhanced Barrier Precautions (EBP). Residents 10, 30, 39, 40, 29, 37, and 28 were identified as needing EBP, but the Infection Preventionist (IP) failed to obtain physician's orders, perform wound assessments, or initiate care plans for these residents. The IP admitted to not completing necessary documentation or assessments, which left the status of the residents' wounds unknown. The DON stated that the IP was responsible for identifying residents needing EBP and ensuring appropriate precautions were in place. The facility's failure to implement EBP and maintain necessary medical equipment as per physician's orders highlights significant lapses in adhering to professional standards of care. The lack of documentation and oversight in infection control measures increased the risk of infection transmission among residents, while the failure to maintain the low air loss mattress compromised the care of Resident 12, potentially leading to the development of pressure ulcers.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 6.9%. This deficiency was identified through observations, interviews, and record reviews. One incident involved an LVN administering an incorrect dosage of lactulose solution to a resident, providing only 20 ml instead of the prescribed 30 ml. This underdosing could prevent the resident from receiving the full therapeutic benefit of the medication, which is used to treat constipation. The resident had a medical history that included alcoholic cirrhosis of the liver and duodenal ulcer, conditions that could be exacerbated by improper medication administration. Another incident involved the same LVN administering metformin to a different resident without food, contrary to the physician's order to give the medication with meals. This oversight could lead to gastrointestinal distress and affect the medication's absorption, potentially compromising blood sugar control. The resident had a medical history of diabetes, anemia, and muscle weakness. Interviews with other staff members, including the Director of Nursing, emphasized the importance of adhering to medication orders to ensure effective treatment and prevent adverse effects.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as observed during a meal service in the dining room. Staff did not provide or assist residents with hand hygiene before serving lunch trays to 11 sampled residents. This oversight was noted during an observation on March 4, 2025, at 11:50 a.m., where residents were assisted by staff for lunch, but no hand hygiene was offered or provided. The lack of hand hygiene placed these residents at increased risk for cross-contamination. Interviews with staff members, including CNAs, an Activities Assistant, an LVN, and the Director of Nursing, revealed a consistent acknowledgment of the failure to provide hand hygiene. CNA 8 and CNA 9 admitted that they did not offer hand hygiene to residents before meals, despite understanding its importance in preventing gastrointestinal issues. The Activities Assistant also confirmed that residents participated in activities involving contact with various surfaces before lunch without subsequent hand hygiene. The Director of Nursing expressed an expectation for staff to ensure residents' hands were cleaned before meals. The facility's policy and procedure on infection prevention and control, dated 2024, mandates that all staff follow established hand hygiene procedures. However, this policy was not adhered to during the observed meal service. The Dietary Aide's job description also emphasizes the importance of following safety and hygiene measures to protect residents, which was not followed in this instance. The failure to provide hand hygiene before meals was a clear deviation from the facility's established protocols, leading to the identified deficiency.
Resident's Right to Smoke Not Upheld
Penalty
Summary
The facility failed to uphold the rights of a resident, identified as Resident 147, by not allowing her to smoke since her admission. Resident 147, who was admitted with multiple diagnoses including psychosis, major depressive disorder, schizoaffective disorder, opioid dependence, and insomnia, expressed a desire to smoke despite medical advice against it. Her Minimum Data Set assessment indicated no cognitive deficits, suggesting she was capable of making informed decisions about her care. Despite being educated on the risks of smoking before her throat healed, Resident 147 consistently expressed her wish to smoke, which was not honored by the facility. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed that they were aware of Resident 147's desire to smoke and her right to do so against medical advice. However, due to an oversight during the admission process, Resident 147 was not identified as a smoker, and no Resident Safe Smoking Assessment was completed. This lack of assessment and documentation led to the failure to include her in the facility's Resident Smoking Binder, which tracks residents who smoke and their supervision needs. The facility's policies and procedures, as well as job descriptions for staff, emphasize the importance of respecting and promoting residents' rights, including the right to make personal choices. Despite this, the facility did not implement Resident 147's choice to smoke, resulting in a violation of her rights and a negative impact on her quality of life, as she experienced increased anxiety and a decreased sense of pleasure during her stay.
Failure to Maintain Resident's Low Air Loss Mattress
Penalty
Summary
The facility failed to provide a safe and homelike environment for Resident 12, as observed during a survey. Resident 12, who was readmitted to the facility with diagnoses including hemiplegia, hemiparesis, dementia, and muscle weakness, was found lying in bed with a low air loss mattress that was turned off and unplugged. This mattress is crucial for distributing the resident's body weight to prevent skin breakdown and pressure ulcers. The resident's Minimum Data Set assessment indicated a moderate cognitive deficit, which may have contributed to their inability to communicate effectively about their discomfort or needs. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, revealed that the low air loss mattress was supposed to be on at all times as per the resident's care plan to prevent skin breakdown. The CNA and LVN both acknowledged the oversight, and the DON confirmed that it was the nursing staff's responsibility to ensure the mattress was functioning properly. The facility's policy on providing a safe and homelike environment was not adhered to, as the unplugged mattress posed a risk to the resident's safety and well-being.
Inadequate Infection Control by Infection Preventionist
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) possessed the necessary competencies and skills to manage residents requiring Enhanced Barrier Precaution (EBP) effectively. This deficiency was identified during interviews and record reviews, revealing that the IP did not follow critical infection control policies and procedures. Specifically, the IP did not place physician's orders for seven residents on EBP, as required by facility policy. Additionally, the IP failed to initiate EBP care plans within 24 hours and did not complete assessments or documentation for the residents' wounds, leaving the status of the wounds unknown. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, open wounds, cellulitis, and muscle weakness. Despite some residents having no cognitive deficits, the lack of proper infection control measures placed them at increased risk for infection. The Director of Nursing (DON) confirmed that the IP was responsible for identifying residents needing EBP and ensuring the necessary precautions were communicated and implemented. The DON expected the IP to obtain physician orders promptly and fulfill her role in infection prevention and control.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a resident with the necessary adaptive eating equipment, specifically a scoop plate, as indicated on her meal ticket. This deficiency was observed when the resident's lunch was served on a regular plate instead of the required scoop plate. The Certified Dietary Manager (CDM) confirmed that the resident's meal ticket specified the need for a scoop plate, which was determined by occupational therapy and listed on the meal ticket. However, the facility did not have a scoop plate available because the only one they had broke the previous day, and a replacement had been ordered but had not yet arrived. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, type 2 diabetes mellitus with ophthalmic complications, muscle weakness, and chronic kidney disease, was observed eating with her fingers due to the absence of the scoop plate. The resident expressed that she typically used a special plate that helped her eat, and without it, she experienced difficulty and delays in finishing her meals. Interviews with various staff members, including the Director of Staff Development, Registered Dietician, Licensed Vocational Nurse, and Certified Nursing Assistant, confirmed that the scoop plate was essential for the resident to eat with limited assistance and that its absence posed a risk for decreased oral intake. The facility's job descriptions and policies indicated that dietary staff were responsible for ensuring meals were plated according to meal tickets, including the provision of adaptive equipment. The Director of Nursing and Administrator both stated that they expected meal ticket orders to be followed accurately. The deficiency was attributed to the lack of a scoop plate, which was a critical adaptive device for the resident's eating needs, and the failure of the facility to ensure its availability and use as required by the resident's care plan.
Deficiency in Room Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain the required minimum square footage per resident in 10 out of 16 rooms during the survey period. Specifically, rooms 1, 2, 5, 6, 11, 12, 14, 15, 16, and 17 did not meet the required 80 square feet per resident for multiple occupancy rooms. Despite this deficiency, the report notes that residents had privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver for these rooms did not adversely affect the health and safety of the residents residing in them.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was at high risk for elopement. The resident, who had a history of traumatic brain injury, alcohol dependence, seizures, and moderate cognitive impairment, managed to leave the facility unsupervised and was found a mile and a half away. The resident had previously eloped by using objects to climb over the facility's fence, and despite measures such as perimeter checks every 15 minutes, the resident was able to elope again. On the day of the incident, a hospitality aide was assigned to monitor the facility's perimeter but was inside the building instead of performing the required checks. A kitchen meal cart was found next to the fence, which the resident used to climb over and leave the premises. The staff was alerted to the resident's absence when the hospitality aide noticed the cart and initiated a head count, leading to the discovery of the resident's elopement. Interviews with staff revealed that the hospitality aide was expected to remain outside and conduct perimeter checks every 15 minutes, but this protocol was not followed. The facility's policy required adequate supervision and removal of potential elopement aids, but these measures were not effectively implemented, resulting in the resident's unsupervised departure.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for elopement, resulting in the resident eloping from the facility. The resident, who had a history of traumatic brain injury, psychosis, and other conditions, was found by a passing motorist half a mile away from the facility. The resident had used a barrel placed on top of a wheelchair to climb over an 8-foot fence surrounding the facility. The incident occurred when the resident was last seen heading towards their room, and shortly after, a call was received from a motorist who found the resident on the side of the road. The facility's maintenance supervisor and other staff confirmed that the resident had used the barrel to climb over the fence, which should not have been left near the fence. The facility's policy on elopement and wandering residents was not effectively implemented, as the resident was able to leave the premises without adequate supervision. The facility had four doors leading outside, with only two equipped with alarms, and the fenced area was used by residents to get fresh air without supervision. The facility's administrator acknowledged that the facility was known for admitting residents at risk of elopement, yet the supervision and security measures in place were insufficient to prevent this incident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for elopement, resulting in the resident leaving the facility unsupervised. The resident, a male with a traumatic brain injury and mild cognitive impairment, was found walking on the side of the road half a mile away from the facility. The resident's care plan identified him as an elopement risk due to impaired safety awareness and wandering behavior, yet he was not on one-to-one monitoring at the time of the incident. On the day of the elopement, the resident was last seen by staff around 10:30 a.m. during a smoke break. The facility was unaware of the resident's absence until a CNA, who was off duty, noticed him walking on the road and returned him to the facility. Interviews with staff revealed that the resident had previously attempted to pick the gate lock and often sat near the gate, trying to leave when staff entered or exited. Despite these behaviors, the resident was not under constant supervision. The facility's front gate, the only entry and exit point, was observed to be functioning properly, with no signs of tampering. Staff members who interacted with the gate on the day of the incident confirmed that it closed securely each time. However, the exact moment and method by which the resident eloped remain unclear. The facility's policy on elopement and wandering residents emphasizes the need for adequate supervision, which was not provided in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for elopement. This resident, diagnosed with traumatic brain injury and dementia, was able to leave the facility unsupervised. The resident was missing for over eight hours before being found by the Sheriff's Department in an orchard a mile away from the facility. The incident occurred when the resident likely exited the facility with a group of visitors, unnoticed by the staff. The resident's care plan, which identified them as an elopement risk due to impaired safety awareness and cognitive function, indicated that the resident should not leave the facility unattended. Despite this, the resident was able to leave the premises, suggesting a lapse in the supervision and security measures that were supposed to be in place. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and the use of door locks and alarms to prevent such incidents. Observations of the facility revealed a 7-foot-tall metal fence surrounding the premises, with locked gates that required a key for access. The Director of Nursing confirmed that the facility was locked, and only staff had keys to the gates. However, the resident was able to leave the facility, likely slipping out with visitors when the gate was unlocked for them. This indicates a failure in the facility's procedures to ensure that residents at risk of elopement are adequately supervised and prevented from leaving the facility without authorization.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with its policy and professional standards for food safety. Brown and gray particles were found on a windowsill above the food preparation sink, which had the potential to contaminate food. The Registered Dietitian (RD) and Certified Dietary Manager (CDM) confirmed that the windowsill should have been cleaned daily, and the facility's policy required weekly sanitation inspections. Additionally, white sediment build-up was found on the exterior of the dishwashing machine, which could harbor bacteria and contaminate dishes. The RD and CDM acknowledged that the build-up should have been cleaned and that the facility's policy was not followed in this regard. The facility also failed to maintain proper air gaps in the food preparation sink and ice machine, which could lead to sewage water backflow and contamination. The Plant Operations Supervisor (POS) and RD confirmed the absence of air gaps and the potential for contamination. The facility's policy required weekly inspections to ensure compliance with sanitation and food service regulations, which were not adhered to in this case. Furthermore, the dishwashing machine's temperature was observed to be below the minimum requirement of 120°F, which could result in improperly sanitized dishes. The RD and CDM stated that the temperature should be between 120°F and 140°F, and the facility's policy required frequent temperature checks and immediate correction of inadequate temperatures. Additional deficiencies included the use of soiled oven mitts by dietary staff and improperly labeled food in the resident's refrigerator. The RD and CDM confirmed that oven mitts should be cleaned daily to prevent food contamination, and the facility's policy required weekly sanitation inspections. Food stored in the resident's refrigerator was not labeled with the resident's name and use-by date, which could lead to giving the food to the wrong resident and compromised food quality. The RD, CDM, and a Certified Nursing Assistant (CNA) confirmed that the food should be labeled according to the facility's policy to ensure proper identification and quality.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and safe environment for residents, staff, and the public. Observations revealed that the kitchen dry storage floor had multiple areas of brown stains, missing and cracked linoleum, exposing the cement underneath with an accumulation of dark gray debris. Interviews with the Certified Dietary Manager, Plant Operations Supervisor, and Registered Dietitian confirmed that the damaged floor was difficult to clean, unsanitary, and could potentially contaminate the food stored in the dry food storage room. The facility's policy and procedure on sanitation inspection and the FDA Food Code were reviewed, indicating that all food service areas should be kept clean, sanitary, and easily cleanable, which the facility failed to comply with. Additionally, the facility floors in common areas and resident rooms had black-colored stains, uneven surfaces, cracked linoleum with an accumulation of black and brown debris, and missing baseboards. Interviews with the Plant Operations Supervisor, Infection Preventionist, and Administrator confirmed awareness of the damaged flooring and the need for repairs to ensure a safe and homelike environment. The Infection Preventionist highlighted that the uneven floor surfaces could cause falls and that clean floors are essential to prevent the spread of germs. The facility's policy on maintaining a safe, clean, comfortable, and homelike environment was reviewed, indicating that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior, which the facility failed to uphold.
Failure to Ensure Anonymous Grievance Submission
Penalty
Summary
The facility failed to follow their grievance policy and procedure for five of 15 sampled residents when it did not ensure they were able to submit grievances anonymously. During a resident council meeting, the residents stated they did not know how to file anonymous grievances. One resident specifically mentioned not knowing how to submit grievances anonymously. Interviews with the Social Services Director (SSD) and the Activities Director (AD) revealed that grievance forms were kept in locations that required residents to ask staff members for access, thus preventing an anonymous submission process. The SSD acknowledged that the current process did not allow for truly anonymous grievance filing and recognized the importance of such a process to prevent fear of reprisal from residents against the facility or staff members. The facility's policy and procedure titled 'Resident and Family Grievances,' dated October 2023, indicated that grievances could be filed anonymously. However, the practice of keeping grievance forms in locked drawers or behind the nurses' station contradicted this policy. The SSD admitted that the facility did not ensure residents could file grievances anonymously without staff intervention, which could deter residents from voicing their concerns. This failure could negatively affect the psychosocial well-being of the residents involved.
Incomplete POLST Forms for Four Residents
Penalty
Summary
The facility failed to maintain accurate medical records consistent with professional standards and practices for four residents. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 1, 4, 13, and 34 were incomplete. The deficiencies included missing physician information such as name, address, phone number, license number, and signature, as well as missing preparer information and additional contact details. These omissions were identified during interviews and record reviews with the Medical Records Director (MRD) and the Director of Nursing (DON). The MRD acknowledged that the POLST forms should have been completed to ensure that the residents' end-of-life care preferences were followed, especially in the event of a transfer to another facility. Resident 1's POLST, dated 8/2/23, was missing all physician information, the preparer's details, and additional contact information. Resident 1 had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 99. Resident 4's electronic medical record (EMR) indicated a Full Code status, while the paper chart indicated a Do Not Resuscitate (DNR) status, leading to a discrepancy in the resident's code status. Resident 4 had a BIMS score of 12, indicating moderate cognitive impairment. Resident 13's POLST, dated 3/13/24, was missing the physician's phone number, and Resident 13 had severe cognitive impairment with a BIMS score of 99. Resident 34's POLST, dated 1/11/24, was missing the physician's printed name and phone number, as well as the preparer's information and additional contact details. Resident 34 was cognitively intact with a BIMS score of 15. The facility's policy and procedure for documentation in medical records, dated 10/22, required that all assessments, observations, and services provided be accurately documented in the resident's medical record. The Medical Records Clerk's job description also emphasized the importance of ensuring that resident records are properly completed before filing. Despite these policies, the facility failed to maintain complete and accurate POLST forms for the four residents, resulting in medical records that did not fully reflect the residents' end-of-life care preferences and treatments.
Failure to Follow Physician's Order for Inhaler Administration
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for Resident 28 when the Director of Staff Development (DSD) did not offer water to rinse her mouth after administering an aerosol oral inhaler. This was observed during a visit, and it was noted that the physician's order specifically required the resident to rinse her mouth with water and spit it back into a cup after using the inhaler. The failure to follow this order had the potential to cause the medication to accumulate in Resident 28's mouth, increasing the risk of developing oral thrush, a fungal infection. Resident 28's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. During an interview, the Director of Nursing (DON) confirmed that the expectation was for the DSD to follow the physician's order to prevent oral thrush. The facility's policy on the provision of physician-ordered services emphasized the importance of adhering to professional standards of quality. Additionally, the Federal Drug Administration's prescribing information for the inhaler medication highlighted the necessity of rinsing the mouth to prevent localized infections such as thrush.
Failure to Label Medications with Resident Identifiers and Expiration Dates
Penalty
Summary
The facility failed to ensure that drugs were labeled with resident identifiers and expiration dates in accordance with the facility's policy and procedure. Specifically, one Fluticasone propionate salmeterol inhaler and one nasal spray medication were found in medication cart 1 without a resident identifier label and expiration date. This was observed during a concurrent observation and interview with the Infection Preventionist (IP) in front of the nurse's station. The IP confirmed that the medications should have been labeled to prevent giving the medication to the wrong resident and to ensure medication efficacy. The Director of Nursing (DON) stated that her expectation was for the inhaler and nasal spray medication to be labeled with resident identifiers and expiration dates. The DON acknowledged that the lack of proper labeling placed residents at risk for medication errors and receiving less effective medications. A review of the facility's policy and procedure titled 'Labeling of Medications and Biologicals' indicated that all medications should be labeled in accordance with federal and state requirements and current accepted pharmaceutical principles, including the resident's name, prescribing physician's name, medication name, prescribed dose, strength, quantity, expiration date, and route of administration.
Failure to Maintain Oxygen Concentrator
Penalty
Summary
The facility failed to follow policy and procedure to monitor and maintain essential equipment in a safe operating condition for one resident when the resident's oxygen concentrator was not routinely monitored and maintained. During an observation and interview, it was noted that the oxygen concentrator had gray particles and dust on the surface, and the filter was not clean. The Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) both acknowledged that the equipment was dusty and should be cleaned, but they were unsure when maintenance last cleaned the filter. The resident expressed an expectation that the oxygen concentrator should be clean and properly maintained. The Director of Nursing (DON) stated that the facility was expected to follow manufacturer instructions for the use and maintenance of the oxygen concentrator but failed to provide the maintenance log and instructions for use (IFUs). The facility's policy and procedure indicated that the oxygen concentrator should be cleaned and maintained according to the manufacturer's recommendations, which include routine maintenance and regular checking of the filters. The facility's Resident-Care Equipment Policy also emphasized the importance of cleaning and disinfecting reusable resident-care equipment to prevent the transmission of pathogens.
Failure to Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms. Specifically, rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, and 17 did not meet the required square footage requirements. Despite this, residents had a reasonable amount of privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system for 17 residents' beds, which are essential for residents to request assistance from nursing staff. During an observation, interview, and record review, it was found that the warning lights above residents' doorways and the monitoring panel located in the nurse's station were not functioning properly. This issue was identified during a series of interviews and inspections conducted by the Maintenance Supervisor (MS), Administrator (ADM), and Director of Nursing (DON). The MS admitted to conducting daily inspections but failed to check the monitoring panel at the nurse's station, leading to the malfunction going unnoticed. Both the ADM and DON confirmed the malfunction during their inspection, and several staff members, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), were unaware of the issue, indicating a lack of communication and oversight. The deficiency was further highlighted during interviews with the Plant Supervisor Environment (PSE) and the ADM, who acknowledged the importance of a functioning call light system for resident safety. The facility's policy and procedure on call lights, dated November 2022, emphasized the need for a properly functioning call light system to ensure residents can call for assistance. However, the MS did not perform a detailed inspection, and the ADM was unaware of the frequency of these checks, leading to the malfunction affecting 17 residents' beds. This failure placed residents' health and safety at risk, as they were unable to call for help and receive immediate assistance from nursing staff.
CNA Worked Without Active Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) met the specific certification requirements, resulting in CNA 1 working without an active CNA certification. The Director of Nursing (DON) and the Director of Staff Development (DSD) were both unaware that CNA 1's certification had expired, leading to CNA 1 being scheduled and working for five days without an active certificate. The DON acknowledged that it was her responsibility to monitor the status of licenses and certificates for all employees and admitted that the facility did not follow its policy and procedure for ensuring CNAs' certificates were active. During interviews, both the DON and the DSD admitted to lapses in their responsibilities. The DSD stated she was responsible for monitoring certifications and helping CNAs with renewals but was unaware of the expiration. The Administrator also confirmed that CNA 1 should not have been scheduled to work without an active certificate and acknowledged her oversight responsibility. The facility's policy and job descriptions clearly outlined the need for active certification, which was not adhered to in this case.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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