Gardena Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardena, California.
- Location
- 14819 S. Vermont, Gardena, California 90247
- CMS Provider Number
- 056019
- Inspections on file
- 32
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Gardena Convalescent Center during CMS and state inspections, most recent first.
A resident with hemiplegia and total dependence on staff for ADLs fell from bed during peri-care, resulting in injuries. The care plan lacked specific instructions on required staff assistance, and only one CNA was present during the incident. Staff interviews confirmed the resident was not centered in bed and that additional help should have been requested, contrary to facility policy and the resident's needs.
A CNA did not report a fall incident involving a resident with significant medical conditions, resulting in a delay in treatment and evaluation. The CNA only reported the resident's headache to the charge nurse, omitting the details of the fall, which was later discovered by nursing staff upon noticing an injury. Facility policy and staff interviews confirmed that all falls or near falls must be reported immediately for resident safety.
A resident with diabetes returned to the facility after an out on pass, but their blood glucose was not checked until four hours later, contrary to the facility's diabetes management policy. The resident's blood sugar was recorded at 333 mg/dl, indicating hyperglycemia, which could have posed a risk for further complications. The Director of Nursing acknowledged the oversight in the assessment process.
A facility failed to develop a care plan for a resident who did not comply with the recommended time frame for returning from out on pass (OOP). The resident, with a history of falls and diabetes, left the facility for extended periods without a care plan addressing this non-compliance. The DON acknowledged the oversight, noting the resident's high fall risk and need for insulin injections.
A facility failed to ensure a high-risk resident had a plan for continuous supervision while out on pass (OOP). The resident, with a history of falls and requiring supervision for transfers, was allowed to leave for 12 hours without adequate monitoring, exceeding the recommended OOP duration. The DON acknowledged the lack of documentation and monitoring, which posed a potential fall risk. Facility policies for therapeutic leave and fall management were not adhered to, failing to provide necessary supervision.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for four residents, including those with conditions like diabetes, dementia, and hypertension. The MRRs for October to December 2024 were missing, as confirmed by the DON, who noted that only five residents received an MRR in October. The facility's policy requires monthly MRRs to prevent adverse medication consequences, but this was not followed, risking unaddressed medication irregularities.
The facility failed to create individualized care plans for two residents, one requiring a plan for outings and another for managing a PICC line. This oversight could negatively impact their care. A resident frequently left the facility without a care plan for safety during outings, while another had a PICC line without a care plan for its management, risking complications. The facility's policy mandates comprehensive care plans, which were not followed.
A resident with decision-making capacity was not informed of a change in their attending physician due to a shift in care level. The facility's policies require residents to be informed and involved in such decisions, but there was no documentation of notification, violating the resident's rights.
A facility failed to report a resident's non-return after leaving on a pass, as required by their policy. The resident, with conditions including osteomyelitis and schizoaffective disorder, did not return, and the facility did not notify law enforcement or CDPH within 24 hours. The DON acknowledged the oversight, which could have led to serious harm.
A resident with multiple medical conditions left the facility and did not return, but the staff failed to report the absence to CDPH or other authorities. Despite the resident's history of leaving and returning, the facility did not document the absence or notify necessary parties, contrary to their policies. Interviews with the DON and ADM highlighted a lack of concern and adherence to reporting procedures.
A facility failed to complete a smoking safety assessment for a resident with multiple diagnoses, including nicotine dependence, and did not assess another resident before allowing them to go out on pass, despite their complex medical conditions. The Director of Nursing acknowledged the incomplete assessments and the potential safety risks involved.
A facility failed to accurately complete the MDS for a resident, potentially affecting their care plan. The resident, admitted with a pressure ulcer, sepsis, and COPD, had a physician's order for a low air loss mattress (LALM) for wound management. However, the MDS did not reflect the use of the LALM, as acknowledged by the MDS Nurse, which contradicted the facility's policy requiring accurate assessments.
A facility failed to conduct a necessary PASRR Level II evaluation for a resident with major depressive disorder and bipolar disorder, despite the resident's severe cognitive impairment and ongoing antidepressant treatment. The DON admitted to not following through with the evaluation, which is required by the facility's policy to ensure appropriate placement and care for residents with mental disorders.
A facility failed to obtain a Level 2 PASRR evaluation for a resident with schizoaffective disorder and other conditions, despite a Level 1 PASRR indicating the need for further assessment. The Director of Nursing acknowledged the oversight, which could delay necessary mental health care. Facility policy requires a Level II review for residents with mental disorders or intellectual disabilities experiencing significant changes.
A facility failed to carry out physician orders for a low air loss mattress for a resident with multiple medical conditions, risking incomplete care and skin breakdown. Additionally, the facility did not ensure smoking safety for another resident with nicotine dependence, as their smoking assessment was incomplete and lacked a physician's order for unsupervised smoking, posing a fire hazard risk.
A facility failed to assess and monitor a resident's smoking safety, leading to unsupervised smoking, and delayed processing of a pain management referral for another resident, resulting in unmanaged pain. The smoking assessment for a resident with multiple diagnoses was incomplete, and the pain management referral for a resident with a recent amputation was delayed by 18 days, causing significant discomfort.
A resident with a pressure ulcer was found lying on a low air loss mattress (LALM) set incorrectly at 350 pounds, despite weighing 132 pounds. This setting error, identified by a treatment nurse, risked worsening the resident's condition. The Director of Nursing confirmed that LALM settings should align with the resident's weight and ulcer severity, as per facility policy.
A resident with dementia and muscle weakness did not receive timely Restorative Nurse Assistant (RNA) services as ordered, which were intended to maintain and improve range of motion and mobility. RNA services were delayed by eight days and provided only three times a week instead of the prescribed five. Interviews with staff revealed that services should have started the day after the order, but no explanation was given for the delay or reduced frequency.
A facility failed to ensure adequate supervision and a hazard-free environment during smoke breaks for a resident with epilepsy and other conditions. The resident was allowed to keep smoking materials and smoke unsupervised, despite an incomplete smoking safety assessment. The DON confirmed the resident was considered an independent smoker, but acknowledged the risk of fire and safety issues due to the incomplete assessment. Facility policies required regular assessments and staff involvement in identifying hazards, which were not effectively implemented.
A resident did not receive necessary dental services, risking oral health issues. Additionally, the resident was administered 1.5 liters of oxygen instead of the 2 liters ordered by the physician, risking oxygen desaturation. The facility's policy required adherence to physician orders for oxygen therapy.
A facility failed to ensure a dialysis emergency kit was available at the bedside for a resident receiving hemodialysis. The resident, with end-stage renal disease and an arteriovenous graft, required the kit for potential bleeding emergencies. The Director of Nursing confirmed the responsibility of licensed nurses to check the kit's availability, as per facility policy.
A resident in an LTC facility experienced a medication error rate of 7.14% due to two errors during medication administration. An LVN failed to administer Calcium Carbonate with Vitamin D and did not check the pulse rate before giving Metoprolol Tartrate, as required by the physician's orders. The resident had conditions including atrial fibrillation and hypertension.
The facility failed to label an opened influenza vaccine vial and remove expired insulin vials from the medication storage room. A nurse admitted to not labeling the vaccine, and expired insulin vials for two residents with diabetes were found. Both residents had severe cognitive impairments and required assistance with daily activities. The facility's policy requires proper labeling and timely disposal of expired medications.
A resident with multiple diagnoses, including quadriplegia and bipolar disorder, did not receive requested dental services despite informing the Social Services Director. The resident's last dental visit was in November 2024, and the Social Services Director failed to document or follow up on the request, contrary to the facility's policy on dental services.
A resident with dementia and malnutrition did not receive a therapeutic diet as ordered, specifically fortified potatoes at lunch, which are crucial for weight gain. The RN confirmed the omission, and the Dietary Services Supervisor could not explain why the fortified potatoes were missing. This failure contravenes the facility's policies on therapeutic diets and weight management.
The facility failed to assess and manage pain in a timely manner for a resident with multiple diagnoses, including cellulitis and phantom limb syndrome. Despite a care plan and physician's orders for regular pain assessment, the resident reported severe pain and had been asking for medication for over two hours before receiving it. The staff's delay in addressing the pain caused the resident to experience anxiety and inadequate pain management.
Failure to Provide Adequate Supervision and Individualized Care Plan During Resident ADL Care
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, muscle wasting, and abnormal gait, who was totally dependent on staff for activities of daily living (ADLs), fell from bed while receiving care. The resident was observed with swelling and discoloration on the right cheek and a dime-sized abrasion on the right elbow. The resident was unable to move the right upper and lower extremities and had slurred speech but could communicate with simple words. The fall happened while a CNA was providing peri-care and turning the resident, during which the resident's weight shifted and resulted in a fall from the bed to the floor. Record review showed that the resident required maximum assistance with transfers and bed mobility and was dependent on staff for all ADLs. The care plan for the resident indicated the need for a safe and hazard-free environment but did not specify the type or number of staff assistance required during care. Interviews with staff revealed that the resident was not positioned in the center of the bed before being turned, and only one CNA was present during the incident. Staff acknowledged that the resident was totally dependent and should not have been turned alone, and that assistance should have been requested to ensure safety. Facility policies required periodic assessment of residents' needs for ADL care, monitoring and modifying care plans as necessary, and ongoing training on patient safety and fall prevention. However, the interventions in the resident's care plan were not individualized to specify the necessary assistance, and staff did not follow procedures to ensure the resident's safety during care, directly leading to the fall and resulting injuries.
Failure to Report Resident Fall Incident by CNA
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to report an incident involving a resident who rolled off the bed while being cleaned and subsequently complained of a headache. The resident, who had a history of a nondisplaced tibial fracture, traumatic subdural hemorrhage, and end stage renal disease, was dependent on staff for activities of daily living and had fluctuating capacity to make decisions. After the incident, CNA 1 picked up the resident, returned her to bed, and only reported the headache to the charge nurse, omitting the details of the fall or near fall. The facility's job description and policies required CNAs to promptly report any resident changes, injuries, or falls to licensed nursing personnel and to use proper techniques for lifting and repositioning residents. Interviews with other staff, including licensed vocational nurses and the Director of Nursing, confirmed that all falls or near falls must be reported immediately so that residents can be properly assessed for injuries. The facility's Fall Management Program and Patient Safety Plan also specified that any episode where a resident loses balance and would have fallen, if not for another person, is considered a fall and must be reported. The failure to report the incident resulted in a delay in the resident's treatment and evaluation. The incident was only discovered when a nurse noticed a bump on the resident's head and the resident reported the fall. The CNA's lack of reporting was identified as a deficiency in competency and adherence to facility policy, as confirmed by the Director of Staff Development and other staff interviews.
Failure to Monitor Blood Glucose After Resident's Return
Penalty
Summary
The facility failed to ensure that a resident's blood glucose level was checked promptly after returning from an out on pass (OOP). The resident, who has a history of diabetes mellitus, was admitted to the facility with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), and a history of falls. Upon returning to the facility at 1:48 a.m., the resident's blood sugar was not checked until 6:57 a.m., resulting in a delay of four hours. This oversight was identified during a review of the resident's progress notes and confirmed by the Director of Nursing (DON), who acknowledged that the blood sugar should have been checked as part of the assessment upon the resident's return. The facility's policy and procedure for diabetes management, dated March 2017, requires monitoring of blood glucose levels when a resident returns after a significant absence. Additionally, the facility's resident assessment policy, dated March 2023, mandates comprehensive assessments that include special treatments and procedures. The failure to adhere to these protocols resulted in the resident's blood sugar being recorded at 333 mg/dl, indicating hyperglycemia, which could have placed the resident at risk for further complications. The deficiency was noted as a failure to follow established guidelines for monitoring and assessing residents with diabetes upon their return to the facility.
Failure to Develop Care Plan for Resident Non-Compliance
Penalty
Summary
The facility failed to ensure that a care plan was developed for a resident who exhibited non-compliance by not returning to the facility within the recommended time frame after going out on pass (OOP). The resident, who was admitted with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and a history of falls, was identified as a high fall risk and required insulin injections daily. Despite these needs, the resident left the facility for extended periods on two occasions, exceeding the recommended four to six hours, without a care plan addressing this non-compliance. The Director of Nursing (DON) acknowledged that a care plan should have been created to address the resident's non-compliance, especially given the resident's high fall risk and diabetes. The facility's policy requires comprehensive care plans to address medical, physical, mental, and psychosocial needs, including when a resident's choice to decline care poses a risk to their health or safety. However, no such care plan was in place for this resident, potentially placing them at risk for injury and inadequate monitoring of their diabetes.
Failure to Supervise High-Risk Resident on Therapeutic Leave
Penalty
Summary
The facility failed to ensure that a high-risk resident had a plan in place for continuous supervision and monitoring while out on pass (OOP). The resident, who was identified as having a high risk for falls due to a history of falls, diabetes mellitus, and chronic obstructive pulmonary disease, was cognitively intact and required supervision for transfers and walking. Despite these needs, the resident was allowed to leave the facility for 12 hours without adequate supervision or monitoring, exceeding the recommended OOP duration of four to six hours. This lack of supervision posed a potential risk for the resident to fall while outside the facility. The Director of Nursing (DON) acknowledged that the staff should have documented the resident's risk factors and monitored the resident's safety and supervision once the resident did not return within the recommended time. The facility's policy and procedure for Out on Pass Therapeutic Leave and Fall Management Program were reviewed, indicating that residents should be aware of the risks associated with leaving the facility and provided with necessary information and support. However, the facility did not adhere to these guidelines, failing to provide adequate supervision to minimize the risks associated with falls for the resident while OOP.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for four of six sampled residents, specifically Residents 15, 30, 37, and 38. This deficiency was identified during a review of the facility's MRR binder, which showed that these residents did not have documented MRRs for the months of October through December 2024. The Director of Nursing (DON) acknowledged the oversight and noted that only five residents received an MRR for October, indicating a lapse in the facility's process to ensure all residents' medication regimens were reviewed monthly. Resident 15, admitted with diagnoses including diabetes mellitus, muscle weakness, and end-stage renal disease, had intact cognition and was dependent on staff for daily activities. Despite these conditions, there was no MRR documented for three consecutive months. Similarly, Resident 37, who had dementia, malnutrition, and muscle weakness, and Resident 38, with dementia, hypertension, and diabetes mellitus, also lacked MRR documentation for the same period. Both residents required significant assistance with daily activities and had varying levels of cognitive impairment. Resident 30, diagnosed with bipolar disorder, heart disease, hypertension, and muscle weakness, also did not have an MRR documented for October, November, and December 2024. The DON confirmed the absence of documentation and explained the facility's practice of having MRRs done monthly, with recommendations from the consultant pharmacist communicated to the physician. The facility's policy, revised in March 2024, mandates monthly MRRs to prevent adverse medication consequences, but this was not adhered to, placing the residents at risk of unaddressed medication irregularities.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for two residents, leading to potential negative impacts on their care. Resident 58, who was admitted with diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, frequently signed in and out of the facility on passes. However, there was no care plan in place to address the resident's needs and safety during these outings. The Director of Nursing acknowledged the absence of a care plan for Resident 58's outings, which could result in inadequate and incompetent care. Similarly, Resident 167, who was admitted with conditions such as atrial fibrillation, hypertension, polyneuropathy, and osteomyelitis, had a PICC line for intravenous medication administration. Despite this, the facility did not create a care plan to manage the PICC line, which posed a risk for complications. A registered nurse confirmed the lack of a care plan for the PICC line, emphasizing its importance for tracking the resident's progress and ensuring continuity of care among the interdisciplinary team. The facility's policy required comprehensive care plans to address residents' medical, physical, mental, and psychosocial needs, which was not adhered to in these cases.
Resident Not Informed of Physician Change
Penalty
Summary
The facility failed to ensure that a resident was involved in the decision-making process and was notified of a change in their attending physician. This deficiency was identified for a resident who had the capacity to understand and make decisions, as indicated by their History and Physical and Minimum Data Set assessments. The resident was not informed about the change of physician, which was made due to a shift in their level of care from skilled to custodial care. The resident expressed that they were unaware of the change and emphasized their right to be informed and to choose their own physician. During an interview, the Director of Nursing confirmed that there was no documentation indicating the resident was notified about the change of physician. The facility's policy and procedure on the choice of attending physician and resident rights clearly state that residents have the right to choose their physician and must be informed of any changes. The failure to notify the resident and involve them in the decision-making process violated their rights as outlined in the facility's policies and federal and state laws.
Failure to Report Resident's Non-Return
Penalty
Summary
The facility failed to implement its policy and procedures on reporting an unusual occurrence when a resident left the facility and did not return. The resident, who had been admitted with diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, had the capacity to understand and make decisions, as indicated in their History and Physical and Minimum Data Set. The resident required partial to moderate assistance with activities of daily living. The facility's out on pass log showed that the resident signed out but did not return, and the facility did not report this to law enforcement or the California Department of Public Health within 24 hours. During an interview, the Director of Nursing acknowledged that the resident left and did not return, and the facility failed to inform the appropriate authorities as required by their policy. The facility's policy, revised in March 2023, mandates reporting unusual occurrences that affect the welfare, safety, or health of residents within 24 hours. The failure to follow this policy had the potential to result in serious harm, injuries, or death for the resident.
Failure to Report Resident's Absence to Authorities
Penalty
Summary
The facility staff failed to report a resident's absence to the California Department of Public Health (CDPH) after the resident left the facility and did not return. The resident, who had diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, was noted to have intact cognitive skills and required partial to moderate assistance with activities of daily living. The resident frequently signed out of the facility on passes but did not return after leaving on a specific date. Despite the resident's history of leaving and returning, the facility did not notify the resident's primary physician, local law enforcement, or CDPH about the resident's failure to return. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility did not document the resident's absence or make necessary notifications. The DON acknowledged the risk of not reporting the resident's absence, while the ADM believed the resident's decision to leave did not impact facility operations. The facility's policies required attempts to contact the resident and documentation of such efforts, as well as reporting unusual occurrences to appropriate agencies. However, these procedures were not followed, resulting in a delay in the investigation by CDPH.
Incomplete Assessments for Smoking Safety and Out on Pass
Penalty
Summary
The facility failed to complete a smoking safety assessment for a resident who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's Minimum Data Set (MDS) indicated intact cognitive skills and a need for partial to moderate assistance with activities of daily living. Despite having a care plan for tobacco use, the resident's smoking assessment was found incomplete. During an interview, the Director of Nursing (DON) acknowledged the incomplete assessment and noted the potential safety issues arising from unsupervised smoke breaks. Additionally, the facility did not conduct an assessment for another resident before allowing them to go out on pass, despite the resident having diagnoses such as osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure. The resident's MDS indicated intact cognitive skills and a need for partial to moderate assistance with daily activities. The facility's out on pass log showed the resident frequently signed in and out, but no assessment was found to determine their ability to leave the facility. The DON confirmed the lack of assessment and highlighted the risk of serious harm or death without proper evaluation.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for one of the sampled residents, which had the potential to negatively affect the plan of care and delivery of services. The resident in question was admitted with diagnoses including a pressure ulcer in the sacral region, sepsis, and chronic obstructive pulmonary disease (COPD). The resident's MDS assessment indicated intact cognitive skills and a need for moderate assistance with upper body dressing and personal hygiene. However, the MDS assessment did not accurately reflect the use of a low air loss mattress (LALM) prescribed for wound management, as it was not marked under section M (Skin Condition) 1200B. During an interview and record review, the Minimum Data Set Nurse (MDSN) acknowledged the oversight, stating that the omission of the LALM on the MDS assessment resulted in providing incorrect information to the facility staff involved in the resident's care. This inaccuracy was contrary to the facility's policy and procedure, which mandates that assessments must accurately reflect the resident's status at the time of the assessment. The policy emphasizes the importance of qualified staff conducting assessments to ensure they represent an accurate picture of the resident's status during the observation period.
Failure to Conduct PASRR Level II Evaluation for Resident with Psychiatric Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) for a resident with an existing psychiatric diagnosis, which is a federal requirement to ensure appropriate placement and care for individuals with mental disorders or intellectual disabilities. The resident, who was readmitted to the facility with diagnoses including major depressive disorder and bipolar disorder, had a Minimum Data Set indicating severe cognitive impairment and was receiving antidepressant medication. Despite these indicators, the resident's PASRR Level I completed in 2019 did not acknowledge a mental illness, and no subsequent Level II evaluation was conducted. The Director of Nursing (DON) acknowledged the oversight in not following through with the necessary PASRR Level II evaluation, which is crucial for determining the appropriate placement and need for specialized services. The facility's policy, revised in March 2023, mandates the completion of PASRR for all residents upon admission and referral to the state for those with mental illness or intellectual disabilities. The policy also requires reporting significant changes in a resident's mental condition to the appropriate state mental health authority, which was not adhered to in this case.
Failure to Obtain Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation was obtained for a resident who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's Level 1 PASRR, dated 01/07/2025, indicated the need for a Level 2 PASRR evaluation, which was not completed. This oversight was identified during a review of the resident's face sheet and Minimum Data Set (MDS), which showed that the resident had intact cognitive skills and required partial to moderate assistance with activities of daily living. During an interview, the Director of Nursing (DON) acknowledged that the resident's Level 1 PASRR was positive for a mental illness and confirmed that a Level 2 PASRR should have been resubmitted. The DON stated that failing to resubmit the PASRR could result in a delay in necessary mental health care and services. The facility's policy, revised in 03/2023, requires a referral for a Level II resident review evaluation for individuals identified by PASRR to have a mental disorder, intellectual disability, or a related condition who experience a significant change.
Deficiencies in Physician Orders and Smoking Safety
Penalty
Summary
The facility failed to ensure physician orders were carried out for a resident who was dependent on activities of daily living and had intact cognitive skills. The resident was ordered to have a low air loss mattress for skin management due to their medical conditions, including spinal stenosis, chronic kidney disease, acute kidney failure, and embolism and thrombosis of the left lower extremity. Despite the order being in place since December 2024, the resident did not receive the mattress and reported the issue to staff members without resolution. The Director of Nursing confirmed the absence of the mattress and acknowledged the risk of incomplete care and potential skin breakdown due to this oversight. Additionally, the facility did not provide services meeting professional standards of quality regarding smoking safety for another resident with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's care plan included adherence to the facility's tobacco/smoking policies, but their smoking assessment was incomplete, and there was no physician's order for unsupervised smoking. The Director of Nursing noted that the incomplete smoking safety notes and lack of a physician's order posed a fire hazard risk. The facility's policy did not address low air loss mattresses or smoking safety.
Failure to Monitor Smoking Safety and Timely Process Pain Management Referral
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's smoking safety, which could have resulted in serious harm. Resident 48, who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy, was observed smoking unsupervised on the facility's smoking patio. The resident's smoking assessment was incomplete, lacking information on whether supervision was required. The Director of Nursing acknowledged the incomplete assessment and the absence of Interdisciplinary Team meetings regarding the resident's smoking safety, which could lead to not knowing if supervision was necessary. Additionally, the facility did not process a pain management referral in a timely manner for Resident 49, who was admitted with conditions such as hypertension, a compression fracture of the spine, and a surgical amputation of the right lower leg. Despite having a physician's order for a pain management referral entered on 1/5/2025, the referral was not processed until 1/22/2025, resulting in unmanaged pain for the resident. Interviews with nursing staff revealed that the delay in processing the referral led to the resident experiencing excruciating pain, as the current pain medications were insufficient.
Incorrect LALM Setting for Resident
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) was set and maintained at the correct setting for a resident, which placed the resident at risk for worsening pressure ulcers and further skin breakdown. The resident, who was admitted with diagnoses including a pressure ulcer in the sacral region, sepsis, and COPD, was observed to be lying on an LALM set at 350 pounds, despite the resident's actual weight being 132 pounds. This incorrect setting was identified during an observation and interview with the treatment nurse, who acknowledged that the setting should be based on the resident's current weight to prevent discomfort and deterioration of the wound. The Director of Nursing confirmed that the LALM setting should be adjusted according to the resident's weight and the severity of the pressure ulcer as determined by the physician. The facility's policy and procedure for low air loss mattresses and treatment services to prevent or heal pressure ulcers emphasize following the manufacturer's guidelines and providing care consistent with professional standards to promote healing and prevent new pressure ulcers. However, the failure to adhere to these guidelines resulted in a deficiency in the care provided to the resident.
Failure to Provide Timely Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received Restorative Nurse Assistant (RNA) services as ordered, which were intended to maintain and improve the resident's range of motion and mobility. The resident, who was admitted with diagnoses including dementia, malnutrition, and muscle weakness, was dependent on staff for various activities and required RNA services five times a week. However, RNA services were not initiated until eight days after the order was placed, and even then, the services were only provided three days a week instead of the prescribed five. Interviews with the Restorative Nursing Assistant and the Director of Rehab revealed that RNA services should have started the day after the order was placed, but neither could explain the delay or the reduced frequency of services. The facility's policy indicated that residents should receive restorative nursing care as needed, but this was not adhered to in the case of the resident, potentially leading to a decline in function or development of contractures.
Inadequate Supervision and Hazard Management During Resident Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment during smoke breaks for a resident, leading to a potential fire hazard. Resident 48, who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy, was observed to have a lighter and an empty pack of cigarettes on their bedside table. The resident stated they were allowed to keep smoking materials and smoke unsupervised on the smoking patio. However, the resident's smoking safety assessment was found incomplete, indicating a lack of proper evaluation of their ability to smoke safely. During an interview, the Director of Nursing (DON) confirmed that residents who were alert and oriented were permitted to possess smoking materials. The DON acknowledged that Resident 48 was considered an independent smoker, but the incomplete smoking safety assessment posed a risk of fire and safety issues. The facility's smoking policy required assessments to be completed on admission, quarterly, and as the resident's needs or capabilities changed, which was not adhered to in this case. Additionally, the facility's policy on accident hazards emphasized the importance of staff involvement in identifying potential hazards, which was not effectively implemented in this situation.
Failure to Provide Dental Services and Proper Oxygen Therapy
Penalty
Summary
The facility failed to ensure dental services were provided for a resident, identified as Resident 110, which had the potential to result in tooth decay, gum disease, bad breath, and cavities. Resident 110 was admitted with diagnoses including dependence on oxygen, thrombocytopenia, anemia, and benign prostatic hyperplasia. The Minimum Data Set (MDS) indicated that Resident 110 had intact cognitive skills but required substantial to maximal assistance with activities of daily living, such as toileting, showering, and dressing. Additionally, the facility did not administer oxygen therapy according to the physician's order for Resident 110. During an observation, it was noted that the resident was receiving 1.5 liters of oxygen via nasal cannula, whereas the physician's order specified 2 liters continuously. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN 2) who acknowledged the risk of not following the physician's order, which could lead to oxygen desaturation. The facility's policy on oxygen therapy required a physician order outlining administration, which was not adhered to in this instance.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident requiring hemodialysis treatment. Specifically, the facility did not ensure that a dialysis emergency kit was readily available at the bedside of a resident with end-stage renal disease, hypertension, and anemia. The resident was scheduled to receive hemodialysis treatment three times a week and had an arteriovenous graft dialysis access site on the right upper arm. During an observation and interview, it was confirmed that the dialysis emergency kit, which should contain dry gauze, tape, alcohol pads, and a bandage, was not available at the bedside. This kit is essential for managing potential excessive bleeding from the dialysis site. The Director of Nursing stated that it was the responsibility of licensed nurses to check the availability of the dialysis emergency kit at the start of each shift and during huddle meetings. The facility's policy and procedure on dialysis management, dated March 2023, indicated that residents requiring dialysis care should receive services consistent with professional standards of practice. The absence of the emergency kit at the bedside was a deviation from these standards and posed a risk of uncontrolled bleeding, which could lead to severe consequences for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors out of 28 medication opportunities, resulting in a cumulative error rate of 7.14% for a resident. The errors involved the failure to administer Calcium Carbonate with Vitamin D as prescribed and the failure to monitor the pulse rate before administering Metoprolol Tartrate, as per the physician's orders. These deficiencies were observed during a medication administration task involving a resident with diagnoses including atrial fibrillation, hypertension, polyneuropathy, and osteomyelitis. During the medication pass observation, a Licensed Vocational Nurse (LVN) did not administer the prescribed Calcium Carbonate with Vitamin D due to the absence of the medication on the cart. Additionally, the LVN administered Metoprolol Tartrate without checking the resident's pulse rate, contrary to the physician's order to hold the medication if the systolic blood pressure was below 110 or the pulse rate was below 60. The facility's policy requires that medications be administered according to orders and that vital signs be checked prior to administration, which was not adhered to in this instance.
Medication Labeling and Expiration Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications, leading to two deficiencies. In the first instance, a vial of influenza vaccine was found in the medication storage room refrigerator without an opened date label. During an observation and interview, a registered nurse acknowledged the absence of the label and the infection preventionist nurse admitted to opening the vial without labeling it. The facility's policy requires that multi-dose vials be dated when opened to ensure safe administration and storage. In the second instance, two unopened vials of expired insulin were found in the medication storage room refrigerator. One vial of Lispro insulin for a resident with diabetes and end-stage renal disease, and one vial of Levemir insulin for another resident with diabetes and chronic obstructive pulmonary disease, were both expired. A registered nurse confirmed the responsibility of licensed nurses to check expiration dates and stated that expired insulin should be discarded immediately. The facility's policy indicates that unopened vials should be discarded according to the manufacturer's expiration date. Both residents involved had severe cognitive impairments and required substantial assistance with daily activities. The failure to label the influenza vaccine and remove expired insulin vials posed a potential risk to the residents' health, as the effectiveness of the medications could be compromised.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one of the six sampled residents, identified as Resident 6. Resident 6, who was admitted with diagnoses including bipolar disorder, quadriplegia, major depressive disorder, and insomnia, had intact cognitive skills and required partial to moderate assistance with activities of daily living. During an interview, Resident 6 reported that he had not received a dental cleaning from the facility's dentist as requested, despite having informed the Social Services Director months ago. The last dental visit for Resident 6 was in November 2024. The Social Services Director acknowledged responsibility for setting and following up on dental appointments for residents. She admitted to writing Resident 6's name on a list for a dental cleaning but was unable to locate the list. Furthermore, she did not document or follow up on Resident 6's request for dental services. The facility's policy, revised in December 2020, mandates that dental services be provided in accordance with professional standards of quality and timeliness. The failure to follow up on dental services had the potential to result in oral health issues for Resident 6.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for one resident, identified as Resident 37, during lunchtime. Resident 37, who was admitted with diagnoses including dementia, malnutrition, and muscle weakness, had an order for fortified potatoes to be served with lunch to address nutritional deficiencies and support weight gain. Despite this order, an observation on January 23, 2025, revealed that Resident 37's lunch tray did not include the fortified potatoes. This omission was confirmed by a Registered Nurse (RN) who acknowledged the importance of the fortified potatoes in preventing further weight loss for the resident. The Dietary Services Supervisor (DSS) was unable to provide an explanation for the absence of the fortified potatoes on Resident 37's lunch tray. The facility's policy on therapeutic diets, dated March 2023, mandates that residents receive foods with appropriate nutritive content to support their treatment and care plans. Additionally, the facility's weight management policy, dated December 2024, emphasizes the provision of therapeutic diets for residents with nutritional problems. The failure to adhere to these policies resulted in a deficiency that put Resident 37 at risk for further weight loss.
Failure to Timely Assess and Manage Pain
Penalty
Summary
The facility failed to assess and manage pain in a timely manner for Resident 3, who was admitted with diagnoses including cellulitis of the left lower limb, phantom limb syndrome with pain, and muscle weakness. Despite a care plan indicating the need for regular pain assessment and management, Resident 3 reported a pain level of 8 out of 10 and had been asking for pain medication since 9:00 a.m. on the day of the observation. The resident had undergone debridement on a right heel pressure ulcer and had pressed the call light multiple times to request pain medication. The Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) involved failed to promptly address the resident's pain, with the LVN admitting to not assessing the pain level before administering medication at 11:20 a.m., over two hours after the initial request. This delay in pain management caused the resident to experience anxiety due to unmanaged pain. Interviews with the Director of Nursing (DON) and a review of the facility's policy and procedure on pain assessment and management highlighted the requirement for proper pain assessment and timely treatment to maintain the resident's quality of life. The facility's policy emphasized the need for assessing pain characteristics, addressing underlying causes, and implementing appropriate pain management strategies. However, the staff's failure to adhere to these guidelines resulted in inadequate pain management for Resident 3, potentially affecting the resident's quality of life and ability to perform daily activities.
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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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