Garden City Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 1310 West Granger, Modesto, California 95350
- CMS Provider Number
- 055185
- Inspections on file
- 32
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Garden City Healthcare Center during CMS and state inspections, most recent first.
A licensed nurse took a photograph of a resident's arm, which was tied to the bed during IV line placement, using her personal phone before the restraint was removed. The resident had dementia, and the use of a personal device to capture the image violated facility policy on privacy and confidentiality.
A resident with impaired mobility was left with an arm positioning device secured to their wrist after a mid-line catheter procedure, restricting arm movement. Multiple staff members noticed the device during shift changes and care, but it was not promptly removed, documented, or reported according to facility policy. This resulted in the resident's arm being unnecessarily restrained and potentially caused discomfort and emotional distress.
A deficiency was cited when an area of the facility was not kept free from accident hazards and lacked adequate supervision to prevent accidents, as required by safety standards.
A resident was allowed to self-administer medications without an assessment of their ability to do so safely. The resident, with multiple diagnoses, was given medications like Norco and gabapentin to take while out on pass, without proper evaluation or training. Nursing staff followed informal practices without consulting administration, and no IDT meeting was held to assess the resident's capability for self-administration, contrary to facility policy.
A facility failed to create a care plan for a resident self-administering medications while out on pass. The resident, with conditions like osteomyelitis and paraplegia, received medications such as Norco and gabapentin without a formal care plan or training. Interviews revealed that medications were given without a guiding policy, and the DON confirmed the need for a care plan to ensure safety.
A resident with a complex medical history experienced an unwitnessed fall and showed signs of delirium. The facility failed to notify the physician promptly and did not conduct necessary assessments, such as neurological, pain, or skin evaluations. This delay in care and communication potentially increased the resident's risk of complications.
A resident with complex medical conditions experienced inadequate pain management when the facility administered acetaminophen for moderate pain instead of the prescribed Hydrocodone-Acetaminophen. Despite reports from family and CNAs about the resident's significant pain, the appropriate medication was not given, leading to unmanaged pain. Facility staff confirmed the resident should have received the stronger medication as per physician orders.
Two residents engaged in sexual activity without the facility assessing their capacity to consent. Despite cognitive impairments and diagnoses such as dementia, the facility did not notify medical professionals or implement protective measures. This led to confusion and distress among residents and staff, as some allowed the activity while others did not, placing residents at risk of abuse.
The facility failed to clean a commercial can opener in the kitchen, leading to potential foodborne illness risks for 98 residents. Observations revealed metal shavings on the blade, and interviews confirmed the can opener was not cleaned per policy, posing a risk of bacteria buildup.
A resident was exposed to her roommate engaging in sexual activity in their shared room, leading to feelings of humiliation and embarrassment. Despite being aware of the situation, the facility did not address the issue. The resident, who required maximum assistance for daily activities, reported the situation to staff, but her complaints were ignored. Facility staff confirmed awareness of the ongoing situation and acknowledged the potential negative psychological impact on the resident.
Two residents were involved in a verbal altercation involving racial slurs and threats, which was not investigated or reported by the facility. Despite policies requiring investigation and reporting of abuse, the facility failed to take appropriate action, leaving the residents at risk for ongoing abuse.
The facility failed to ensure the safe use and storage of Emergency kits (Ekits) for 98 residents. At the North Station, three IV medication Ekits were found open and unsealed, with no documentation on their use. Additionally, two refrigerated Ekits containing controlled drugs were open and missing medications, with no documentation of removal. Staff acknowledged the findings, and the Director of Nursing confirmed that the facility's policy on Ekit management was not followed.
The facility failed to ensure safe medication storage practices, with hazardous drugs stored without proper labeling, outdated and undated medications in carts, and missing emergency drug kits. Staff were unaware of handling precautions, and facility policies were not followed, posing risks of unsafe medication use.
The facility failed to follow infection prevention measures for two residents receiving IV antibiotics through PICC lines, as staff did not wear gowns as required by Enhanced Barrier Precautions. Additionally, aseptic techniques were not used when reconstituting IV antibiotics, as alcohol wipes were not applied to medication vial stoppers. Furthermore, dirty cups were improperly placed with clean cups on a coffee cart, risking cross-contamination. These actions were contrary to the facility's infection control policies.
A resident with epilepsy, osteoporosis, and dementia was unable to reach her call light due to a contracted hand, leaving her unable to communicate with staff for assistance. Despite being dependent on staff for all physical needs and at high risk for falls, the call light was not placed within her reach, contrary to her care plan and facility policies. This deficiency was confirmed by the DON.
The facility failed to report abuse allegations involving four residents to the state agency. Two residents engaged in sexual activity without the capacity to consent, and a verbal altercation with threats and racial remarks occurred between two other residents. The facility did not follow its policies on abuse prevention and reporting, leading to a delay in addressing potential abuse and safeguarding residents.
A facility failed to accurately complete the PASARR Level 1 screening for a resident with schizoaffective disorder and bipolar disorder, resulting in a negative screening outcome. The resident exhibited aggressive behavior and delusions, consistent with her diagnoses, but the necessary referral for a Level II evaluation was not made, as confirmed by the DON. This oversight was due to the facility not following its admission policy and procedure.
A resident with a history of falls and neurological conditions did not receive complete neurological assessments after a fall, as required by their care plan and facility policy. The resident, who had Parkinson's disease and cognitive impairment, fell and hit their head, prompting an order for scheduled neurological checks. However, these assessments were not fully completed, and the resident was later found not breathing and died. Facility staff confirmed the assessments were incomplete, and the policy was not followed.
A resident who preferred to communicate in Greek was not provided with interpreter services, despite the facility's care plan indicating the need for such services. Staff were unaware of the availability of interpreter services, and the facility's policies on effective communication and resident rights were not followed, resulting in a deficiency in the resident's care.
A resident left cigarettes and a lighter unattended on a patio, accessible to other residents, contrary to the facility's smoking policy. The resident, with a history of COPD and other conditions, was assessed as safe to use smoking products, but their care plan required these items to be stored at the nurses' station. Staff interviews confirmed that smoking materials should be kept in medication carts and smoking was only allowed in designated areas, highlighting a failure to follow the facility's policy.
The facility failed to monitor high-risk medications for two residents. One resident received a blood pressure medication against hold parameters, while another had no physician's order for blood sugar monitoring while on insulin. These oversights were confirmed through MAR reviews and staff interviews.
The facility's Antibiotic Stewardship Program failed to track and assess antibiotic use as per policy for 98 residents. The Infection Prevention nurse did not document critical information such as the duration of therapy, culture dates, or outcomes in the tracking log. Empiric antibiotic use was not monitored, and there was no follow-up for de-escalation. The facility's policy requirements for documenting and reviewing antibiotic regimens were not met, leading to the deficiency.
The facility failed to maintain infection control standards as air filters in AC units across several hallways were found caked with dust and debris. Observations confirmed that filters had not been changed as required, with no documentation of maintenance for several months. The Maintenance Director and Administrator acknowledged the oversight, which contradicted facility policy and CDC guidelines.
The facility failed to document post-fall assessments for three residents who experienced falls, despite having a policy requiring monitoring for late injuries. Interviews confirmed the absence of necessary documentation, which should have been conducted to monitor for late injuries or changes in neurological status.
A facility failed to document essential details for a resident's transfer to an acute care hospital, including the date, time, destination, mode of transportation, and disposition of personal effects and medications. The DON confirmed the lack of necessary documentation and acknowledged that the facility's emergency transfer policy was not followed.
A resident with COPD did not receive her prescribed Trelegy Ellipta inhaler for several days, and the physician was not informed of the unavailability. The medication was mistakenly placed in the destruction pile, contrary to the facility's pharmacy policy.
A resident with COPD and morbid obesity fell from bed while a CNA was changing her fitted sheet, resulting in multiple injuries. The resident's care plan required two-person assistance for bed mobility, but the CNA performed the task alone, contrary to facility policies.
Resident Privacy Breach Due to Staff Use of Personal Phone
Penalty
Summary
A licensed nurse (LN) used her personal phone to take a photograph of a resident's right arm while it was tied to the bed during an intravenous (IV) line placement. The nurse was informed by a night shift nurse that the resident's arm had been tied, and before instructing the nurse to untie the arm, she took a picture with her personal device. The resident involved had been admitted with diagnoses including dementia, which affects memory, thinking, and social abilities. The facility administrator confirmed that the photograph was taken on the nurse's personal phone, which may not have been encrypted and could potentially be accessed by unauthorized individuals. Facility policy requires employees to treat residents with kindness, respect, and dignity, and to maintain privacy and confidentiality of resident information. The act of taking a photograph with a personal phone constituted a failure to maintain the resident's privacy and confidentiality.
Failure to Remove Arm Positioning Device After Procedure
Penalty
Summary
A deficiency occurred when a resident's right wrist remained secured in an arm positioning device following a mid-line catheter insertion. The device, intended to stabilize the arm during the procedure, was not removed after completion, leaving the resident unable to move their arm freely. Multiple staff members, including CNAs and LNs, became aware of the device during shift changes and routine care, but the device remained in place for an extended period. The use of the device was not documented, nor was its continued presence reported to the licensed nurse on duty by the nurse who performed the procedure. The resident involved had a medical history that included a recent fall, abnormal gait, and impaired mobility, making them particularly vulnerable to hazards. Staff interviews revealed that the arm positioning device was noticed by several caregivers during their shifts, but there was confusion and lack of clear communication regarding its removal. One CNA removed the device temporarily to provide care but replaced it afterward, while a licensed nurse was informed about the device but did not remove it, instead passing the information to the next shift. Another nurse instructed that the device should be removed, but it remained in place until further inquiry. Facility policy required that hazardous equipment and devices be identified and addressed to ensure resident safety. The failure to remove the arm positioning device, document its use, and communicate its status to the appropriate staff resulted in the resident's arm being unnecessarily restrained and secured to the bedframe. This situation had the potential to cause discomfort and emotional distress to the resident, as confirmed by the administrator and clinical nurse officer during interviews.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. There is no mention of specific residents, staff, or detailed events, but the deficiency centers on the lack of appropriate hazard control and supervision in the area.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe and clinically appropriate self-administration of medications for Resident 1, who was not assessed for self-administration before being provided medications to take while out on pass. Resident 1, diagnosed with osteomyelitis, paraplegia, and chronic pain, was given medications such as Norco, gabapentin, and Sivextro to self-administer without a proper assessment or training. The resident reported taking medications to school since the summer of 2024, with nurses placing the medications in envelopes for him. Interviews with nursing staff revealed that they routinely provided Resident 1 with medications to take on pass without consulting administration or following a specific policy. LN 1 and LN 2 admitted to giving medications in baggies based on observed practices from other nurses, without receiving formal training or guidance. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the practice and confirmed that no Inter-Disciplinary Team (IDT) meeting was held to evaluate the safety and appropriateness of Resident 1's self-administration of medications. The facility's policy on self-administration of medications requires an IDT assessment to determine a resident's cognitive and physical abilities to safely self-administer medications. This includes understanding medication labels, following directions, and comprehending the purpose and dosage of medications. The DON confirmed that there was no documentation in Resident 1's medical record regarding training on safe handling or self-administration of medications, which is crucial to prevent potential harm from improper medication use.
Failure to Develop Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was self-administering medications while out on pass from the facility. The resident, who had diagnoses including osteomyelitis, paraplegia, and chronic pain, was given medications such as Norco, gabapentin, and Sivextro by facility staff to take with him to school. However, there was no care plan in place to address the self-administration of these medications, and the resident had not received training on how to properly take them while away from the facility. Interviews with the resident and facility staff revealed that the medications were provided in envelopes or baggies without a formal policy or care plan guiding this practice. The Director of Nursing confirmed that a care plan should have been developed to ensure the resident's safety and proper medication administration. The facility's policy indicated that self-administration of medications should be determined by the interdisciplinary team as clinically appropriate and safe, but this process was not followed for the resident in question.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide adequate care and services following an unwitnessed fall involving a resident. The resident was found on the floor next to his bed in the early hours of the morning, exhibiting signs of delirium. Despite this, the Licensed Nurse (LN) delayed notifying the physician until several hours later. The nurse also failed to document a neurological, pain, or skin evaluation, which are critical assessments following a fall, especially when the resident shows signs of confusion and delirium. The resident had a complex medical history, including liver cirrhosis, muscle weakness, and a recent amputation, which increased his risk for falls and complications. His care plans specifically required monitoring and reporting signs of delirium to the medical doctor. However, the nurse did not adhere to these protocols, as evidenced by the incomplete SBAR Communication Form and the lack of immediate physician notification. The Assistant Director of Nursing confirmed these lapses during a review of the incident. Interviews with family members and staff further highlighted the resident's condition and the facility's response. The family member noted the resident's increased confusion and pain prior to the fall, and staff reported the resident's distress and physical injuries after the fall. Despite these observations, the necessary assessments and timely communication with the physician were not conducted, potentially delaying treatment and increasing the risk of further complications for the resident.
Inadequate Pain Management for Resident with Moderate Pain
Penalty
Summary
The facility failed to provide comprehensive and effective pain management for a resident, identified as Resident 1, who was experiencing moderate pain. Despite having a pain assessment scale indicating moderate pain, Resident 1 was administered acetaminophen, a medication intended for mild pain, instead of the prescribed Hydrocodone-Acetaminophen for moderate to severe pain. This discrepancy in medication administration occurred on multiple occasions, including when Resident 1 reported a pain level of 5 and 6, which were categorized as moderate pain. Resident 1 was admitted to the facility with several complex medical conditions, including dehiscence of an amputation stump, cirrhosis of the liver, end-stage renal disease, and ascites. The resident's pain was not effectively managed, as evidenced by the administration of acetaminophen for moderate pain levels, contrary to the physician's orders. The resident's family member and certified nursing assistants (CNAs) reported that Resident 1 was in significant pain, and the CNAs repeatedly informed the licensed nurse (LN 1) of the resident's condition. However, the appropriate pain medication was not administered in a timely manner. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Medical Doctor (MD), confirmed that the resident should have received Hydrocodone-Acetaminophen for moderate pain. The facility's policy and procedure for administering medications emphasized the importance of following prescriber orders and administering medications based on resident needs. The failure to adhere to these guidelines resulted in Resident 1 experiencing unmanaged pain, which was further complicated by the resident's complex medical history.
Failure to Assess Consent Capacity for Sexual Activity
Penalty
Summary
The facility failed to protect the rights of two residents, Resident 32 and Resident 38, to be free from abuse and neglect. The facility was aware that these residents were engaging in sexual activity but did not assess their capacity to consent to such activities. Despite the ongoing relationship, the facility did not notify the medical doctor or psychiatrist to assist in determining if both residents were capable of consenting to the sexual relationship. This lack of assessment and communication led to a situation where the residents were allowed to engage in sexual activity without a clear understanding of their ability to consent. Resident 32 was admitted with diagnoses including cerebral infarction, hypertension, and myocardial infarction, and had a history of cognitive impairment with a BIMS score indicating moderately impaired cognition. Despite this, the facility did not involve Resident 32's psychologist or notify the responsible party about the sexual relationship. Similarly, Resident 38, who had diagnoses including dementia and bipolar disorder, was also not assessed for her capacity to consent, and her medical records indicated she did not have the capacity to make her own decisions. The facility's failure to implement protective measures or involve relevant healthcare professionals left both residents vulnerable to potential abuse. The facility's inaction resulted in confusion and distress for the residents, as some staff allowed the sexual activity while others prevented it. This inconsistency, coupled with the lack of a formal process to evaluate residents' capacity for consent, placed not only Resident 32 and Resident 38 at risk but also other vulnerable residents in the facility. The facility's failure to address these issues promptly and effectively created a likelihood of serious physical and psychosocial harm to occur.
Improper Cleaning of Kitchen Equipment
Penalty
Summary
The facility failed to maintain cleanliness standards for a commercial can opener in the kitchen, which could have led to foodborne illnesses for 98 residents. During an observation and interview with the Dietary Director, it was noted that the can opener had old metal shavings on its blade, indicating it was not cleaned properly after use. The Dietary Director acknowledged the oversight and confirmed that the can opener should be cleaned after each use and deep cleaned weekly, although there was no log to track these cleanings. This lack of proper cleaning posed a risk of infection and potential foodborne illnesses. Further interviews with the cook and the Registered Dietitian revealed that the facility's policy required the can opener to be cleaned after each work shift and more frequently if necessary. The Registered Dietitian confirmed that the policy was not followed, as the can opener was not cleaned after each use or run through the dishwasher after each shift. The presence of metal shavings on the blade could have led to bacteria buildup, increasing the risk of residents becoming ill. The failure to adhere to the established cleaning procedures directly contributed to the deficiency.
Failure to Ensure Resident's Right to Dignity
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence when a resident, identified as Resident 49, was exposed to her roommate and another resident engaging in sexual activity in their shared room. Despite being aware of the situation, the facility did not address the issue, leading to Resident 49 feeling humiliated and embarrassed. Resident 49, who was admitted in 2023, had diagnoses including arthritis and depression, and required maximum assistance with transfers, bathing, dressing, and personal hygiene. She reported the situation to the staff, but her complaints were not heeded. Interviews with facility staff, including the Activity Assistant and the Director of Nursing, confirmed that the facility was aware of the sexual activity occurring in Resident 49's room. The Activity Assistant acknowledged that the situation had been ongoing since January 2024 and that there was no known policy regarding residents engaging in sexual activity. The Director of Nursing confirmed that Resident 49 could not leave the room without assistance and acknowledged the potential negative psychological impact on residents unable to leave the room during such activities. The facility's policies on dignity and resident rights emphasize treating residents with respect and ensuring their well-being, which were not upheld in this situation.
Failure to Investigate and Report Resident Altercation
Penalty
Summary
The facility failed to investigate and implement safeguards following allegations of verbal abuse and threats of physical violence between two residents, Resident 311 and Resident 25. Resident 311, who was admitted with conditions including cellulitis, anxiety, and depression, reported to the Ombudsman that her roommate had used a racial slur against her. The Ombudsman noted that the incident was a verbal altercation and that Resident 311 was asked to move rooms, which she felt was unfair. The facility's Case Manager 1 reportedly told Resident 311 that if she did not move, the police would be called, and suggested she could leave the facility if unhappy with her care. Certified Nursing Assistant 4 witnessed an altercation between the two residents, where they exchanged derogatory names and threats, and involved Licensed Nurse 7 for assistance. Despite the altercation, the facility's Administrator acknowledged that there was no follow-up or investigation into the incident, nor was it reported to the state agency. The Administrator stated that typically such incidents would involve an interdisciplinary team meeting and monitoring of the residents, which did not occur in this case. The facility's policies on abuse prevention and reporting require that all allegations of abuse be investigated and reported to the appropriate agencies. However, the review of Resident 311's clinical record confirmed that no investigation or reporting took place. This lack of action placed both residents at risk for ongoing abuse, as the facility did not adhere to its own policies or federal requirements to protect residents from abuse and ensure their safety.
Deficiency in Emergency Kit Management
Penalty
Summary
The facility failed to ensure the safe use and storage of Emergency kits (Ekits) for a census of 98 residents. At the North Station, three Ekits for IV medications were found open and unsealed, with no documentation on when they were opened, what was removed, or which residents the medications were used for. The Ekits contained disorganized IV medications, premixed antibiotics, and IV solutions, some without a beyond-use date. Licensed Nurse (LN) 3 was unable to provide information on why the Ekits were left open and unsealed or when they were last used. The facility's records showed sparse documentation of IV medication and supply use, with only a few entries in recent months. Additionally, two refrigerated Ekits containing controlled drugs, such as lorazepam, were found open and unsealed in a locked room. These kits were missing medications, including Ativan and insulin, with no documentation of their removal. LN 2 and LN 3 acknowledged the findings and indicated that staff should have documented the removal of medications and faxed the usage slip to the pharmacy for kit replacement. The Director of Nursing (DON) confirmed that the staff should have documented any medication or supplies removed from the Ekits and re-sealed them with a yellow color sealer. The facility's policy, dated 2019, requires that only authorized individuals trained in the appropriate use of emergency kits may obtain medications from them. The policy mandates that Ekits be stored in a secured area and that any drug removal be documented with specific details. However, the policy did not address how Ekit replacement and medication removal, including controlled drugs, should be handled by nursing staff. The DON acknowledged that the staff might not have followed the facility's policy regarding Ekit medication removal.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed in multiple instances across different medication carts and stations. At the North station, hazardous medications like Megestrol were stored without proper warning labels or protective bags, and the nursing staff was unaware of the necessary precautions for handling such drugs. Additionally, an extra IV medication cart contained a large supply of prescription IV medication bags without patient-specific labels or a tracking system, leading to potential misuse or misadministration. Further inspection revealed that the IV medication cart at the North station stored outdated and undated medications, including those for residents no longer in the facility. The cart was cluttered, with discontinued and active medications co-mingled, and lacked proper labeling for beyond-use dates. At the South station, the medication cart and refrigerator contained undated, unlabeled, and outdated medications, including missing emergency drug kits. This included expired insulin pens, improperly stored probiotics, and unaccounted controlled medications like Lorazepam. The facility's policies on medication storage and handling were not followed, as evidenced by the lack of proper labeling, dating, and storage of medications. The Director of Nursing acknowledged these deficiencies, noting that the facility's procedures for handling controlled substances and emergency kits were not adhered to. These lapses in medication management could lead to unsafe medication use and pose risks to residents receiving spoiled or unusable medications.
Infection Control Deficiencies in Resident Care and Facility Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, Resident 300 and Resident 60, who were receiving intravenous antibiotics through Peripherally Inserted Central Catheter (PICC) lines. During observations, a Licensed Nurse (LN) entered the rooms of these residents wearing only a facemask and gloves, despite Enhanced Barrier Precautions (EBP) signs indicating the need for gown and glove use during high-contact activities such as device care. The LN admitted to not wearing a gown, acknowledging the risk of spreading infection. The Infection Preventionist and Director of Nursing confirmed that the EBP policy was not followed, which was intended to prevent the transmission of multi-drug resistant organisms. Additionally, the facility did not adhere to aseptic techniques when reconstituting intravenous antibiotics for the same residents. The LN was observed not using an alcohol wipe on the rubber stopper of a medication vial before connecting it to a bag of normal saline. The LN believed the stopper was sterile and did not require wiping, contrary to the standard practice of using alcohol wipes to disinfect small surfaces. The Director of Nursing confirmed that the expectation was to use alcohol wipes, aligning with CDC guidelines for disinfection and sterilization in healthcare facilities. Furthermore, the facility failed to maintain proper infection control practices with the coffee cart used in resident areas. Dirty cups were found stacked alongside clean cups on the cart, posing a risk of cross-contamination. Both a Certified Nursing Assistant and a Licensed Nurse acknowledged that dirty cups should not be placed on the coffee cart, and the Director of Nursing confirmed that the procedure was not followed. The facility's Infection Prevention and Control Program policy emphasized the importance of standard precautions, including the separation of clean and dirty items to prevent the spread of infection.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 37, had her call light within reach, which is crucial for her to communicate with the nursing staff for assistance. Resident 37, who has a diagnosis of epilepsy, osteoporosis, and dementia, was observed in her bed with a contracted right hand, unable to reach the call light that was hanging off the right side of the bed rail. This situation was verified by a Licensed Nurse, who acknowledged that the resident was dependent on staff for all physical needs and was at high risk for falls. The nurse stated that the call light should have been placed near the resident's left hand or an adaptive call light should have been used. The resident's care plan indicated that she had severe cognitive impairment and was at high risk for falls, with interventions including keeping the call bell within reach. However, during the observation, it was noted that these interventions were not followed. The Director of Nursing confirmed that the facility's policies and procedures, which require the call light to be within easy reach of residents, were not adhered to. The failure to accommodate the resident's needs and preferences, as outlined in the facility's policies, resulted in the deficiency noted in the report.
Failure to Report Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency after incidents involving four residents. Two residents, who lacked decision-making capacity, engaged in sexual activity without the ability to consent. Despite staff awareness and documentation of their relationship, the facility did not implement safeguards to prevent sexual contact or report the situation to the state agency. The residents' medical records indicated cognitive impairments, and their responsible parties were not adequately informed about the sexual activities, leading to a lack of proper consent assessment. Another incident involved a verbal altercation between two residents, which included threats of physical violence and racial derogatory remarks. The altercation was not documented in the clinical records, and there was no investigation or report to the state agency. The facility's staff failed to hold an interdisciplinary team meeting to address the altercation and ensure resident safety. The lack of documentation and follow-up actions contributed to the deficiency in handling the situation. The facility's policies on abuse prevention and reporting were not followed, as the incidents were not reported to the appropriate authorities within the required timeframes. The administrator and other staff members were aware of the incidents but did not take the necessary steps to protect the residents or investigate the allegations. This failure to act in accordance with the facility's policies and federal requirements resulted in a delay in addressing the potential abuse and safeguarding the residents' well-being.
Inaccurate PASARR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for a resident, identified as Resident 20, who was diagnosed with schizoaffective disorder and bipolar disorder. The PASARR Level 1 screening, conducted prior to the resident's admission, incorrectly indicated that the resident did not meet the criteria for a serious mental illness, resulting in a negative screening outcome. This error was identified during a review of the resident's clinical records, which showed multiple instances of aggressive and combative behavior, as well as delusions, all of which are consistent with her diagnosed mental health conditions. The facility's policy and procedure for admissions, which requires a Level 1 PASARR screening for all potential admissions, was not followed in this case. The Director of Nursing confirmed that the PASARR Level 1 was not completed correctly, and the necessary referral to the state PASARR representative for a Level II evaluation was not made. This oversight could have prevented the resident from receiving the appropriate mental health services needed to address her conditions.
Failure to Complete Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 96, received the necessary neurological assessments following a fall, as outlined in the resident's care plan and facility policy. Resident 96 had a history of muscle wasting, cognitive impairment, and Parkinson's disease, which increased their risk for falls. After being admitted to the facility from an acute care hospital, Resident 96 experienced a fall in their room, during which they hit their head and sustained discoloration to their buttocks and left knee. The primary care provider ordered scheduled neurological assessments to monitor for potential changes in the resident's condition. However, the neurological assessments were not fully completed as required. Specifically, assessments were missed at two critical times, which could have led to a delay in identifying any neurological changes. The resident was later found not breathing and subsequently died. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, confirmed that the neurological assessments were incomplete, and the facility's policy and procedure for neurological assessments were not followed. This oversight could have resulted in missing significant changes in the resident's neurological status.
Failure to Provide Language Interpreter Services
Penalty
Summary
The facility failed to ensure effective communication for a resident whose preferred language is Greek, which could have impacted her ability to maintain or improve her communication skills. During observations and interviews, it was noted that the resident was unable to respond to questions in English and communicated primarily by pointing at objects and using a few English words. The care plan for the resident indicated the need for interpreter services due to impaired communication, but staff members, including licensed nurses and certified nursing assistants, were unaware of the availability of such services and did not utilize them. The Director of Nursing (DON) and other staff members confirmed that there were no Greek-speaking staff available and that interpreter services had not been used for the resident. The facility's policies and procedures on effective communication and resident rights, which require assistance for residents with language barriers, were not followed. The DON acknowledged that the staff could have been using interpreter services to communicate effectively with the resident, but this was not done, leading to a deficiency in the resident's care.
Resident Smoking Materials Left Unattended
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for one of the residents, identified as Resident 84, who left cigarettes and a cigarette lighter accessible to other residents on a patio. Resident 84 was admitted to the facility with several diagnoses, including a wedge compression fracture, neuropathy, and COPD. Despite being assessed as safe to maintain and use smoking products, Resident 84's care plan indicated that their cigarettes and lighter should be stored at the nurses' station. However, during an observation, Resident 84 was seen smoking on a patio outside their room, leaving the smoking materials unattended and accessible to other residents. Interviews with facility staff, including a Licensed Nurse, the Assistant Director of Nursing, and the Director of Nursing, revealed that the facility's policy required residents' smoking materials to be kept in medication carts and that smoking was only allowed in designated areas. The Director of Nursing confirmed that the facility's policy was not followed, as residents were not permitted to smoke on patios outside their rooms due to safety risks, especially for those on oxygen. The facility's smoking policy, revised in October 2023, stated that residents with independent smoking privileges could keep smoking items in their possession, but the policy was not adhered to in this instance.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to monitor the use of high-risk medications for two residents, leading to potential adverse drug effects. For one resident, the nursing staff did not adhere to the hold parameters for a blood pressure medication, Florinef, which was administered seven times despite a physician's order to withhold it when the resident's systolic blood pressure exceeded 130. This oversight was confirmed during a review of the resident's Medication Administration Record (MAR) and an interview with a licensed nurse, who acknowledged the failure to follow the prescribed parameters. For another resident, the facility did not have a physician's order or parameters for monitoring blood sugar levels while the resident was on two insulin products. The nursing staff measured the resident's blood sugar without guidance on managing high or low levels, which could lead to inconsistency in treatment. This lack of parameters was confirmed during a review of the resident's MAR and an interview with a licensed nurse, who noted the absence of orders for blood sugar testing upon the resident's readmission from the hospital. The Director of Nursing acknowledged that the monitoring and parameters should have been addressed upon readmission.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its Antibiotic Stewardship Program (ASP) effectively tracked and assessed antibiotic use according to its policy for a resident census of 98. During an interview, the Infection Prevention nurse (IP) revealed that when a new antibiotic was ordered or a resident was admitted with an antibiotic order, he was notified and would enter the information into a spreadsheet for tracking. However, the spreadsheet lacked critical information such as the duration of antibiotic therapy, date of culture, and outcome or stop date for the drug. The IP also admitted that empiric antibiotic use was not tracked, and there was no follow-up to de-escalate antibiotic use once test results were available. Additionally, the criteria to assess the development of an infection by nursing staff before contacting a doctor were not utilized. Further review revealed that the facility's policy required antibiotic usage and outcome data to be collected and documented using a facility-approved tracking form, which was not adhered to. The IP stated that culture results were not documented in the antibiotic use tracking record, and individual physician prescribing patterns were not tracked or shared with other healthcare providers. The Director of Nursing acknowledged the importance of monitoring in-house antibiotic use and working with doctors to optimize appropriate use, especially for residents with long-term IV antibiotic use. The facility's policy outlined specific requirements for documenting and reviewing antibiotic regimens, which were not met, leading to the deficiency.
Inadequate Maintenance of AC Units Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain proper infection prevention and control standards due to the condition of air filters in freestanding air conditioning units located in various hallways. Observations made on September 27, 2024, revealed that the air filters in units at the ends of the North long hall, North short hall, South long hall, and South short hall were caked with dust and debris. This condition was confirmed during interviews with the Maintenance Director and the Administrator, who acknowledged that the filters appeared not to have been changed and were overdue for replacement. The Maintenance Director admitted that the air conditioning units were installed at the beginning of summer and that the filters should be changed monthly and as needed. However, there was no documentation in the maintenance logs indicating that the filters had been changed in July, August, or September 2024. The facility's policy, dated June 2011, required weekly inspections and monthly changes of air filters during use. Additionally, the CDC guidelines and the operation manual for the AC units emphasized the importance of regular maintenance to prevent the spread of airborne infections, highlighting the facility's failure to adhere to these standards.
Failure to Document Post-Fall Assessments for Residents
Penalty
Summary
The facility failed to meet professional standards of care for three residents who experienced falls, as post-fall documentation was not completed. Resident 1, admitted with dementia, was found on the floor with injuries to the head and wrist, but lacked 72-hour post-fall monitoring documentation. Similarly, Resident 2, with muscle weakness and a left below-knee amputation, was found on the bathroom floor after a fall, yet there was no follow-up documentation for three days post-fall. Resident 3, with a history of falls and Alzheimer's disease, experienced a fall from a wheelchair resulting in a laceration, but also lacked the required post-fall documentation. Interviews with the Director of Nurses and licensed staff confirmed the absence of necessary post-fall documentation for all three residents, which should have been conducted to monitor for late injuries or changes in neurological status. The facility's policy, dated 2001, mandates monitoring and documentation following falls to rule out delayed complications, but this protocol was not followed for the residents in question.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident when she was transferred to an acute care hospital. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and a urinary tract infection, was transferred without documentation of the date and time of transfer, the destination hospital, the mode of transportation, or the disposition of her personal effects and medications. The progress notes indicated that the resident was receiving acute care outside the facility, but there was no physician's order for the transfer or a completed transfer form. During an interview and record review, the Director of Nurses (DON) confirmed that the resident's health record lacked necessary documentation for the transfer. The facility's policy and procedure for emergency transfers, which requires notifying the attending physician, the receiving facility, and preparing a transfer form, was not followed. The DON acknowledged that the documentation should have been completed as per the facility's policy.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident when the resident did not receive her prescribed medication, Trelegy Ellipta, and the physician was not informed that the medication was unavailable. The resident, who was admitted with chronic obstructive respiratory disease (COPD), did not receive her medication from 3/16/24 to 3/20/24, which she stated sometimes worsened her breathing. The licensed nurse (LN) and the Director of Nurses (DON) confirmed the medication was missing and that the physician had not been notified of the missed doses. The DON discovered that the medication had been delivered on 3/14/24 but was mistakenly placed in the medication destruction pile and documented as destroyed on 3/17/24. The facility's pharmacy policy requires that the physician be notified if a vital medication is unavailable, but there was no documentation indicating that the physician was informed about the missed doses. This oversight had the potential to negatively impact the resident's health and well-being.
Resident Falls from Bed During Sheet Change
Penalty
Summary
The facility failed to provide a safe environment for a resident when the resident fell from bed while her fitted sheet was being replaced. The resident, who had chronic obstructive pulmonary disease (COPD) and morbid obesity, was admitted to the facility in 2007. During the incident, the resident was being given a bed bath and was turned on her side to change the fitted sheet. The resident was holding onto the side rail but let go, resulting in a fall that caused lacerations to her left great toe and right knee, a nosebleed, and a hematoma on her forehead. The CNA involved stated that the resident was on an air mattress, which may have been too soft, and he was unable to prevent the fall when she let go of the rail. A review of the resident's care plan indicated that she required two-person assistance for bed mobility due to her weakness and obesity. The CNA, however, was performing the task alone. The facility's policy and procedure for repositioning residents in bed required staff to check the care plan for specific positioning needs and the number of staff required. Additionally, the facility's fall risk assessment policy emphasized the need to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan. The Director of Nurses confirmed that the CNA should have reviewed the resident's care information, which was accessible through the electronic charting system, to ensure proper assistance was provided.
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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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