Gordon Lane Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fullerton, California.
- Location
- 1821 E Chapman Ave, Fullerton, California 92831
- CMS Provider Number
- 555797
- Inspections on file
- 32
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Gordon Lane Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including uncovered clean linen being transported and left unattended, failure to notify public health and implement contact isolation for a resident with unresolved scabies, a CNA using the same gown and gloves between two residents (one on EBP), and instances where a urinary catheter drainage bag and negative pressure wound therapy tubing were found touching the floor. Staff interviews and policy reviews confirmed these lapses.
The facility did not have a program in place to monitor antibiotic use, resulting in a lack of systematic tracking or evaluation of antibiotic prescribing and administration for residents.
Staff failed to follow infection control protocols for a resident on contact precautions for scabies, including not donning an isolation gown before care and improperly discarding used PPE in a regular trash bin. Additionally, clean linens were placed on a dirty hamper, leading to contamination. These actions were confirmed by facility leadership and staff.
A CNA exposed her breasts to a resident who was unable to make decisions, and the facility failed to report the incident to authorities, notify the resident's responsible party, initiate an abuse investigation, or monitor the resident's status as required by policy. Staff interviews revealed a lack of awareness and no in-service training was provided following the event.
A resident did not receive multiple prescribed medications upon readmission because pharmacy orders were electronically misfiled and not processed, resulting in a delay of several days before medications were delivered. Nursing staff identified the issue, contacted the pharmacy, and notified facility leadership, but the medications remained unavailable until the error was discovered and corrected.
The facility failed to securely store medications, with a resident's multivitamin left on a bedside table without a self-administration assessment, and Hibiclens cleanser left unattended in a shower room. These actions posed a risk of unauthorized access.
A facility failed to update a resident's care plan to include the use of a wound vac for a pressure ulcer on the sacrococcyx area, as ordered by the physician. The care plan did not reflect the prescribed treatment of cleaning the wound, applying a granulating foam, sealing with a transparent dressing, and connecting to a wound vac at 150 mmHg every Monday, Wednesday, and Friday. This oversight was confirmed during a medical record review and acknowledged by the DON.
A facility failed to follow infection control practices during high-contact care for a resident with a medical device and pressure injury. The Treatment Nurse did not wear a gown or perform hand hygiene as required, posing a risk of disease transmission. The DON confirmed the expectation for staff to use PPE and perform hand hygiene during such activities.
A facility failed to report an allegation of staff-to-resident abuse to the CDPH, L&C Program in a timely manner. A resident with intact cognition called 911, alleging rough handling by a CNA during care. Despite the police visiting the facility, the incident was not reported to the appropriate authorities, as confirmed by interviews with the Administrator, DON, and SSD.
A facility failed to follow its abuse policy by not removing an accused CNA from resident care areas during an investigation of alleged physical abuse. The CNA continued working as the police deemed the allegation unsubstantiated. Additionally, the facility did not report the investigation results to the CDPH L&C Program, posing a risk to the involved resident and others.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not obtaining informed consent for quetiapine use, inadequately monitoring behavior and side effects of medications, and not providing non-pharmacologic interventions. Staff confirmed the lack of documentation and monitoring, and the administrator acknowledged these deficiencies.
A resident, who was severely cognitively impaired, was subjected to verbal abuse by a CNA who used foul language in Spanish when the resident asked for help. A student nurse witnessed the incident and reported it, leading to the facility substantiating the abuse. The facility's policy emphasizes resident protection, yet this incident occurred, and the CNA was suspended.
A facility failed to follow infection control practices by placing a COVID-19 positive resident in the same room as a COVID-19 negative resident, contrary to CDC guidelines. This occurred due to a miscommunication during admissions, leading to a high risk of infection transmission. The error was identified and corrected the following day.
The facility failed to ensure the proper recording of personal belongings for two residents, leading to incomplete inventory forms and unlisted items. One resident's form lacked a date and signature, while another's form was missing a signature and had unlisted belongings. Staff confirmed these discrepancies during interviews and observations.
A resident with mild cognitive impairment and frailty syndrome missed a scheduled telemedicine neurology consultation because no staff member was present to assist during the appointment. The Case Manager was unavailable and did not delegate the task, leading to the resident not attending the consultation.
A facility failed to create a comprehensive care plan for a resident with mild cognitive impairment likely due to vascular dementia. Despite the resident's medical records indicating a need for a neurology consult and highlighting their vulnerability to cognitive decline, the care plan did not address these issues. This was confirmed by the DON during a review, posing a risk for inadequate care.
A facility failed to maintain accurate medical records for a resident by not documenting the administration of a prescribed treatment. The resident's Treatment Administration Record (TAR) lacked the nurse's initials for two scheduled applications of a warm compress, as required by the facility's policy. The LVN responsible for the resident's care confirmed the omission, and the DON reiterated the policy for documenting treatments.
The facility failed to ensure proper storage and labeling of medications, with issues found in Medication Room A, the Central Supply Room, and treatment and medication carts. Unsealed packages, expired medications, and unsanitary conditions were observed, and a zinc oxide ointment was left unattended.
The facility failed to ensure proper food preparation, storage, and sanitary requirements in the kitchen, leading to potential foodborne illnesses. Observations included improperly labeled and dated foods, a heavily marred chopping board, a discolored can opener, and utensils with water residue. These deficiencies were confirmed by the Dietary Services Supervisor.
The facility failed to ensure proper infection control practices, including the use of expired disinfectant wipes, improper handling of medical equipment, and inadequate hand hygiene. Staff did not follow Enhanced Barrier Precautions, and community supplies were not sanitized between uses, increasing the risk of infection spread.
The facility failed to ensure the call light system was fully functional, resulting in inaudible call lights at nursing stations and delayed responses to residents' needs. Observations confirmed that the call lights in several rooms were not working properly, and specific residents reported unaddressed call light activations.
A resident was administered Seroquel and paroxetine without documented informed consent. The informed consent forms were not signed by the physician, and the facility's verification form was incomplete. Interviews with staff confirmed the oversight, and the facility's policies on informed consent were not followed.
The facility failed to ensure call light accessibility for two residents and did not respond promptly to another resident's call light. The DON and Administrator acknowledged these deficiencies.
A facility failed to develop and implement a comprehensive care plan for a resident receiving Vancomycin IV therapy for a UTI/sepsis. The care plan was not updated promptly, leading to a delay in individualized care and monitoring.
The facility failed to update a resident's comprehensive care plan to include necessary treatments for both lower extremities to maintain skin integrity from cellulitis related to venous insufficiency. Despite physician's orders for specific treatments, the care plan did not reflect these interventions, as confirmed by staff interviews and medical record reviews.
A facility failed to follow a physician's orders for wound care on a resident's right lower leg. An LVN used Derma Klenz instead of soap and water and did not use a protective drape, contrary to the prescribed treatment. The DON acknowledged the deficiency.
The facility failed to follow physician's orders for wound care on a resident's pressure injuries, leading to improper treatment. The LVN did not apply Santyl ointment as ordered and used Derma Klenz instead of normal saline. Additionally, protective pads were not used, and the resident's diaper was not properly managed, potentially worsening the pressure ulcers.
The facility failed to ensure a resident was positioned safely at 30 to 45 degrees during enteral feeding via a gastrostomy tube (GT). The resident was observed slouched in bed multiple times while the GT feeding pump was on, and there was no documentation of education provided to the resident's family members regarding proper positioning.
The facility failed to clean a resident's BiPAP mask according to its policies and procedures, as confirmed by the resident and an LVN. The resident, who was cognitively intact, reported that the mask had never been cleaned since admission. The DON acknowledged the issue and confirmed that a treatment order for cleaning was placed only after the deficiency was identified.
The facility failed to provide appropriate pain management for two residents, leading to unmanaged pain and distress. One resident with diabetic neuropathy and a pressure ulcer did not receive timely pain medication, and another resident did not receive pain medications according to physician's orders. Staff interviews confirmed these deficiencies.
The facility failed to monitor fluid restriction for two residents receiving dialysis services. Both residents had documented fluid intake exceeding their prescribed limits, and staff admitted to not accurately recording the specific amounts of fluids consumed. The RD also did not audit the total fluid intake, relying on nursing staff for this information.
The facility failed to ensure nursing services were provided by appropriately trained staff, as evidenced by two CNAs improperly handling residents' oxygen equipment and two other CNAs not following Enhanced Barrier Precautions due to inadequate training.
The facility failed to accurately document controlled medications for two residents and did not replace oral and IV E-Kits within the required 72-hour timeframe. Discrepancies in medication counts and delayed E-Kit replacements posed risks for medication diversion, administration errors, and unavailability of emergency medications.
The facility failed to act on the Pharmacy Consultant's recommendations for a resident taking gabapentin, methadone, and Dilaudid. The recommendations included monitoring for CNS and respiratory depression and placing hold parameters for gabapentin. An RN confirmed that these recommendations were not followed, and there was no documented evidence of the required monitoring or hold parameters.
The facility failed to maintain a medication error rate below 5%, resulting in a 24% error rate. Two LVNs administered partial doses of medications to two residents due to medication residue left in the cups, and one LVN failed to check a resident's heart rate before administering metoprolol as required by the physician's orders.
A facility failed to ensure an LVN checked a resident's heart rate before administering metoprolol, as required by the physician's orders. The LVN acknowledged forgetting to perform the check and subsequently verified the heart rate after being instructed to stop. The DON confirmed the oversight and the existence of the physician's order.
The facility failed to follow the menu and portion control guidelines, resulting in incorrect servings of cheese ravioli, pureed breadstick and butter, and missing items like butter, milk, and coffee for residents. Additionally, a resident received two desserts instead of one without requesting it.
The facility failed to ensure the food served was palatable, as three residents were served roast beef that was tough and hard to cut or chew. The Dietary Services Supervisor confirmed these findings during an observation and interview.
The facility failed to ensure that residents on a pureed diet were provided with food prepared in a form to meet their individual needs. An observation revealed that the pureed vegetable lasagna contained tiny carrot bits, posing a choking hazard. The facility's policy requires pureed foods to be smooth with no lumps.
The facility failed to honor a resident's documented dislike for dairy products, serving them a meal containing milk despite clear instructions. This discrepancy was observed during food preparation and confirmed by the resident's family member.
The facility failed to maintain complete and accurate medical records for two residents. One resident's ADL-Bed Mobility documentation was incomplete for several dates, and another resident received medications without physician-signed informed consents. The Medical Records Director, RN, and DON verified these deficiencies during interviews.
The facility failed to ensure that a glucometer was maintained in safe operating condition, as the quality control log did not match the test strips' lot number and control solution ranges. This discrepancy was confirmed by an LVN, indicating a lapse in following required procedures for quality control checks.
The facility failed to promote the dignity and respect for a resident. During a lunch meal observation, a CNA was observed standing over a resident while assisting and feeding him. The CNA acknowledged this was inappropriate, and both an RN and the DON confirmed that the CNA should have been seated and at eye level with the resident during feeding times.
A resident's responsible party raised concerns about staff not answering call lights and residents almost falling. Despite these concerns, there was no documented evidence that the facility addressed the grievance. The DON confirmed that no investigation follow-up was documented.
Multiple Infection Control Deficiencies Identified
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, as evidenced by direct observations, interviews, and review of facility policies and procedures. One incident involved a laundry rolling rack with clean residents' clothing being transported uncovered through hallways and left unattended, contrary to facility policy requiring clean linen to be covered during transport and storage. Staff verified that the linen should not have been left uncovered or unattended, acknowledging the lapse in infection control protocol. Another deficiency was identified in the management of a resident with unresolved scabies. Despite ongoing symptoms and treatment with Elimite cream and Ivermectin, the resident was not placed on contact isolation after the initial treatment failed, and there was no follow-up skin testing or consultation with a dermatologist. The facility also failed to notify the local public health department about the unresolved case, as required by both facility policy and public health guidelines. Interviews confirmed that the resident continued to have generalized, crusty rashes and increased itchiness, and that the public health nurse was not informed of the situation. Additional infection control breaches included a CNA using the same gown and gloves to provide care to two different residents, one of whom was on enhanced barrier precautions (EBP), which is against CDC standards and facility policy. Observations also revealed that a resident's indwelling urinary catheter drainage bag and another resident's negative pressure wound therapy tubing were both found touching the floor, which staff acknowledged should not occur to prevent contamination and infection. These findings were confirmed through interviews with staff and review of relevant medical records and facility policies.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program indicates that antibiotic prescribing and administration were not being systematically monitored or assessed by the facility staff.
Infection Control Deficiencies: PPE Use and Linen Handling
Penalty
Summary
Staff failed to adhere to infection prevention and control practices for a resident placed on contact precautions due to scabies. During an observation, a CNA was seen inside the resident's room feeding the resident without wearing an isolation gown, despite a contact precautions sign posted outside the room instructing staff to don PPE before entry. The CNA stated that there was no isolation gown available at the designated supply area and acknowledged that a gown should have been worn. After donning a gown and completing care, the CNA discarded the used gown in a regular trash bin, which was overflowing with used gowns, instead of the designated biohazard bin. The CNA explained that the appropriate bin was not available in the room at the time. Further interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the CNA did not follow proper gowning and disposal procedures. The IP stated that gowns must be donned before entering isolation rooms and disposed of in the correct bin. The Environmental Services Director also acknowledged the lack of a designated trash bin for used PPE in the room and stated that designated bins had been provided and checked the previous day. Additionally, improper handling of clean linens was observed. A CNA was seen placing clean linen on top of a dirty hamper outside the resident's room. Both the CNA and the Environmental Services Director confirmed that this was not in accordance with facility policy, which requires clean linens to be handled and stored in a manner that prevents contamination. The IP verified that the clean linens were now considered contaminated due to this action.
Plan Of Correction
F880 Infection Prevention & Control A. How the facility plans to correct the specific deficiencies cited: * Failure to ensure staff donned an isolation gown and properly discarded it: Immediate in-service education was provided to CNA 4 on June 17, 2025, regarding proper donning, doffing, and disposal of isolation gowns, emphasizing the importance of donning prior to entering an isolation room and proper disposal in designated biohazard bins. All nursing staff and environmental services staff will receive mandatory re-education on June 25th regarding the facility's Infection Prevention and Control policies and procedures, specifically focusing on: * Correct application and removal of all types of Personal Protective Equipment (PPE), particularly isolation gowns, when providing care to residents on transmission-based precautions. * Proper disposal of contaminated PPE into designated biohazard waste receptacles immediately after removal. * The importance of ensuring designated biohazard bins are readily available and not overflowing in isolation rooms. Environmental Services will implement a daily checklist for all isolation rooms to ensure adequate stock of PPE (including isolation gowns) at the designated supply area outside the room and the availability of empty biohazard waste bins within the room starting June 25th, 2025. This checklist will be reviewed by the Environmental Services Director or designee. * Failure to handle clean linens to prevent the spread of infection: Immediate re-education was provided to CNA 5 on June 18, 2025, regarding the proper handling and storage of clean linens, emphasizing that clean linens must never be placed on dirty hampers or other contaminated surfaces. All nursing staff and environmental services staff will receive mandatory re-education on June 25th, 2025 on the facility's policy for Handling Clean Linen, reinforcing the importance of: * Maintaining separation between clean and dirty linens at all times. * Transporting and storing clean linens in clean, designated containers or carts. * Never placing clean linens on or near contaminated surfaces, including dirty hampers. Nursing staff will be re-educated on the proper procedure for bringing clean linens into resident rooms to ensure they remain free from contamination. B. How other residents having the potential to be affected by the same deficient practice will be identified and what corrective action(s) will be taken: * All residents requiring transmission-based precautions will be identified through daily review of the facility's infection control log and resident care plans by the Infection Preventionist (IP) and Director of Nursing (DON). * An audit will be conducted for all residents currently on transmission-based precautions to ensure proper PPE is available outside their rooms and that appropriate waste receptacles are provided within their rooms. Any discrepancies will be immediately corrected. * The IP and DON will conduct focused observations during routine rounds to ensure all staff are consistently adhering to proper PPE utilization and disposal for all residents on transmission-based precautions. All nursing staff and environmental services staff will be re-educated on June 25th, 2025 on proper linen handling procedures to prevent contamination, ensuring all residents receive care with uncontaminated linens. C. What measures will be put into place or systemic changes made to ensure that the deficient practice does not recur: * Enhanced Staff Education and Competency: Comprehensive in-service training on Infection Prevention and Control, including proper PPE use, disposal, and clean linen handling, will be conducted for all nursing staff (RNs, LVNs, CNAs) and environmental services staff by July 15, 2025. This training will include practical demonstrations and return demonstrations to ensure competency. New employee orientation will include a dedicated and enhanced module on infection prevention and control practices. Annual competency evaluations will include observation of proper PPE use and linen handling for all staff involved in resident care. * Increased Environmental Monitoring during Angel Rounds: The existing Angel Rounds checklist will be revised to include specific checks for all resident rooms, especially those with residents on isolation precautions: * Verification of PPE availability: During Angel Rounds, nursing supervisors/designees will visually confirm that appropriate PPE (e.g., isolation gowns, gloves) is stocked and readily accessible at the designated supply area outside isolation rooms. * Trash Bin Monitoring: During Angel Rounds, nursing supervisors/designees will visually inspect all trash bins within resident rooms and bathrooms to ensure they are not overflowing with used PPE or other waste and that designated biohazard bins are present and utilized for waste disposal. The QAPI Committee will review all infection control incidents, audit results, and staff competency records on a monthly basis for a period of six months, and quarterly thereafter. Specific data points to be monitored will include: * Number of observed instances of non-compliance with PPE use and disposal. * Number of observed instances of improper clean linen handling. * Completion rates of staff education and competency evaluations related to infection control. * Findings from Angel Rounds related to PPE and trash bin monitoring. The QAPI Committee will track trends related to infection control practices and identify areas requiring further intervention, such as additional staff training, revised procedures, or environmental modifications. Corrective actions will be implemented as needed based on QAPI findings, and their effectiveness will be continuously evaluated by the QAPI Committee. The Administrator, DON, and IP will be responsible for overseeing the implementation of this Plan of Correction and ensuring ongoing compliance.
Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policies after an incident involving a certified nursing assistant (CNA) exposing her breasts in a resident's room. The incident was witnessed by another CNA, who reported that the CNA in question lifted her scrub top and exposed her breasts to the resident, who was awake at the time. The CNA later admitted to the exposure and stated it was a joke, referencing the resident's birthday. The resident involved was unable to make decisions and was rarely or never understood, as documented in their medical record and Minimum Data Set (MDS). Despite the incident, the facility did not report the alleged abuse to the appropriate authorities, including the state agency, ombudsman, law enforcement, or the resident's responsible party, within the required timeframes. The facility's policy required immediate reporting of abuse allegations, but there was no documented evidence of such reporting. Additionally, the facility did not initiate an abuse investigation, nor did it monitor the resident for clinical or psychosocial status following the incident. There was also no care plan developed in response to the alleged incident. Interviews with facility staff, including the Administrator and Director of Staff Development (DSD), revealed a lack of awareness and action regarding the incident. The Administrator considered the event a code of conduct issue rather than abuse, and the DSD described it as a rumor rather than a reportable event. No in-service training was provided to staff regarding the code of conduct or sexual abuse prevention after the incident was reported. These failures resulted in the facility not protecting the resident from potential abuse and not following required procedures for investigating and reporting such allegations.
Plan Of Correction
F 610 Corrective Action To Correct Deficiency: • On 5/24/25, upon being made aware of the allegation, CNA 10 was immediately suspended pending the outcome of an investigation and has since been terminated. • On 5/30/25, Resident 4 was assessed by the licensed nurse for any adverse clinical or psychosocial effects related to the incident, with none noted. • On 5/30/25, the facility initiated a formal investigation into the allegation of abuse. • On 5/30/25, Resident 4's physician and responsible party were notified of the incident and the investigation. • On 5/30/25, the incident was reported to the California Department of Public Health (CDPH), the long-term care ombudsman, and local law enforcement. • On 5/30/25, a care plan was initiated for Resident 4 to include interventions for psychosocial monitoring by licensed nurses and social services. Corrective Action To Correct Deficiency: • On 5/14/25, all of Resident 2's medications were received from the pharmacy and administered per physician orders. • On 5/14/25, Resident 2 was assessed by a licensed nurse for any adverse signs or symptoms related to the delayed medication administration. The resident's physician was notified, and no adverse effects were identified. Identify Any Other Residents Who May Have Been Affected By the Deficient Practice: • On 6/13/25, the DON initiated a full audit of all new admissions and readmissions from 5/12/25 to 6/13/25 to verify that all admission medication orders were received from the pharmacy and administered in a timely manner. No other residents were identified as being affected by a similar issue. Systemic Change To Prevent Recurrence: • On 6/11/25, licensed nursing staff were re-educated by the DON on the facility's Medication Reconciliation P&P for new admissions and readmissions. The training emphasized the process for verifying receipt of medications from the pharmacy within 24 hours of admission. • Effective 6/12/25, a new verification process was implemented. The nursing unit manager or designee on each shift is now required to use a "New Admission/Readmission Pharmacy Checklist" to verify that all new medication orders have been faxed to the
Failure to Administer Prescribed Medications Upon Readmission Due to Pharmacy Processing Error
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for one of five sampled residents following readmission. Upon review of the medical records, it was found that the resident had multiple physician orders for medications including omeprazole, venlafaxine, lamotrigine, lisinopril, metformin, metoprolol, vitamin C, acetaminophen, magnesium hydroxide, gabapentin, vitamin B-12, clonidine, and dextromethorphan-guaifenesin. Despite these orders, the resident did not receive the majority of these medications upon readmission, with only gabapentin being available initially. Interviews with nursing staff revealed that the medications were not delivered as expected, prompting the LVN to contact the pharmacy, refax the orders, and notify both the nursing supervisor and the physician. The medications remained unavailable for several days, and further attempts were made to communicate with the pharmacy and notify the DON. The delay in medication delivery persisted from the day after readmission until at least two days later, during which time the resident did not receive the prescribed treatments. A review with the Pharmacy Manager identified that the resident's readmission orders were electronically misfiled, resulting in the medications not being processed or delivered in a timely manner. The pharmacy's tracking log confirmed delays in receiving and processing the orders, with some medications not being sent until days after the initial request. Facility leadership, including the DON and Administrator, verified these findings during interviews.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure medications were stored securely, as evidenced by two separate incidents. In the first incident, a resident had a bottle of One a Day Multivitamin/Multimineral on the bedside table, which was accessible to another resident who was observed self-propelling in a wheelchair into the room. The facility's policy requires an assessment for self-administration of medications, which was not completed for this resident. RN 1 confirmed the presence of the multivitamin and removed it, acknowledging that the assessment had not been conducted. In the second incident, a bottle of Hibiclens antiseptic skin cleanser was found unattended on the grab bars in a shower room. CNA 1 confirmed that the cleanser should not have been left there, and the DON later acknowledged that it was not supposed to be unattended. These lapses in medication storage posed a risk of unauthorized access by non-licensed staff and visitors.
Failure to Update Care Plan for Wound Vac Treatment
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect the current wound care treatment and interventions as ordered. Specifically, the care plan did not include the use of a wound vac for the treatment of a pressure ulcer on the sacrococcyx area, as prescribed by the physician. The physician's order, dated from June 8, 2022, to September 15, 2022, required cleaning the wound with normal saline, applying a granulating foam, sealing with a transparent dressing, and connecting to a wound vac at 150 mmHg every Monday, Wednesday, and Friday during the day shift for 30 days. However, the care plan dated July 8, 2022, did not incorporate these specific wound vac instructions. During a review of the closed medical record for the resident, it was confirmed that the care plan lacked the necessary updates to include the wound vac treatment. An interview with RN 1 revealed that the care plan should have been individualized and updated to reflect the current treatment and interventions for the resident's pressure ulcer. The Director of Nursing (DON) acknowledged these findings, indicating a lapse in ensuring the care plan was comprehensive and up-to-date, which posed a risk of not providing individualized and person-centered care for the resident.
Infection Control Deficiency During High-Contact Care
Penalty
Summary
The facility failed to implement effective infection control practices, specifically during high-contact care activities for a resident with an indwelling medical device and a pressure injury. The Centers for Disease Control and Prevention (CDC) guidelines recommend the use of personal protective equipment (PPE), including gowns and gloves, during such activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, during a wound care observation, the Treatment Nurse did not wear a gown while treating the resident's pressure injury and failed to perform hand hygiene before resuming the resident's tube feeding. The deficiency was confirmed by the Director of Nursing (DON), who acknowledged that staff are expected to don gloves and gowns and perform hand hygiene during high-contact care activities, including wound treatment. The failure to adhere to these infection control practices posed a risk for the transmission of diseases and infections within the facility.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when the facility did not report an allegation of staff-to-resident abuse in a timely manner to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The incident involved a resident who had an intact cognition, as indicated by a BIMS score of 14, and who called 911 to report that a Certified Nursing Assistant (CNA) was rough during a brief change. Despite the police visiting the facility in response to the resident's call, the facility did not report the incident to the appropriate authorities. Interviews conducted with the facility's Administrator, Director of Nursing (DON), and Social Services Director (SSD) confirmed that they were aware of the resident's 911 call and the subsequent police visit. However, they acknowledged that no report was sent to the CDPH, L&C Program regarding the incident. The CNA involved in the allegation stated that he reported the incident to the charge nurse, yet the facility's policy of immediate reporting to the Administrator and other appropriate agencies was not followed, leading to the deficiency.
Failure to Implement Abuse Policy and Report Investigation Results
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures regarding the investigation of an alleged physical abuse incident involving a resident. The policy required the removal of the accused employee from resident care areas during the investigation, but the facility did not suspend the accused CNA. Instead, the CNA continued to work on the day of the alleged incident. The facility's internal investigation was conducted while the police were present, but the accused CNA was not removed from duty because the police deemed the allegation unsubstantiated. The facility only reassigned the CNA to a different resident. Additionally, the facility did not report the results of the abuse investigation to the California Department of Public Health Licensing and Certification Program (CDPH L&C Program) as required. The investigation summary was completed and signed by the Administrator on the same day as the incident, but there was no documented evidence that the summary was sent to the CDPH L&C Program. These failures posed a risk to the resident involved and other vulnerable residents in the facility.
Failure to Monitor and Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by several deficiencies in their care. The facility did not obtain informed consent from the resident or their surrogate for the use of quetiapine, a medication used to treat bipolar disorder. Additionally, the facility did not adequately monitor the resident's behavior or the side effects and adverse effects of the psychotropic medications, including citalopram, quetiapine, divalproex sodium, and lorazepam. The facility's policy and procedure on the use of psychotropic medication required that residents be monitored for their response to medications, including progress towards goals and the presence or absence of adverse consequences. However, the resident's medical record lacked documentation of behavior monitoring and interventions for a period of time, and there was no evidence of monitoring for side effects or adverse effects of the medications. Furthermore, the facility did not provide non-pharmacologic interventions to facilitate the reduction or discontinuation of the psychotropic drugs, as required by their policy. Interviews with facility staff, including LVNs and an RN, confirmed the lack of informed consent, monitoring, and documentation for the psychotropic medications. The staff acknowledged that there were no physician's orders for monitoring the side effects of the medications, and the monitoring records were absent from the medication administration record (MAR). The facility administrator was made aware of these findings and acknowledged the deficiencies.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident's rights to be free from verbal abuse by a staff member. A student nurse witnessed a Certified Nursing Assistant (CNA) using foul language in Spanish towards a resident who was asking for help. The incident was reported, and the facility's investigation substantiated the occurrence of verbal abuse. The resident involved was severely cognitively impaired and unable to recall the incident during an interview. The facility's policy on abuse, neglect, and exploitation, revised in December 2022, emphasizes the protection of residents' health, welfare, and rights. Despite this policy, the incident occurred, and the facility documented the event in their SOC 341 form. The administrator confirmed that other residents assigned to the CNA did not report verbal abuse, and the CNA was immediately suspended following the incident.
Improper Cohorting of COVID-19 Positive and Negative Residents
Penalty
Summary
The facility failed to adhere to infection control practices by improperly cohorting a COVID-19 positive resident with a COVID-19 negative resident. Resident 8, who tested positive for COVID-19, was placed in the same room as Resident 9, who tested negative. This action was contrary to CDC guidelines, which recommend that patients with confirmed SARS-CoV-2 infection be placed in a single-person room or cohorted only with others who have the same respiratory pathogen. The facility's infection preventionist (IP) confirmed that it was not the facility's policy to cohort COVID-19 positive residents with those who tested negative. The incident occurred due to a miscommunication during the admissions process, where the admissions team was unaware of Resident 8's COVID-19 positive status. Resident 8 was initially admitted to Room A, where Resident 9 was later admitted, despite Resident 8's need for isolation precautions. The IP discovered the error the following day and moved Resident 8 to a different room. The IP acknowledged that Resident 9 was at high risk for developing a respiratory infection due to this oversight.
Failure to Properly Record Resident Belongings
Penalty
Summary
The facility failed to properly record the personal belongings of two residents, which could lead to the loss or theft of their items. For Resident 2, the Clothing and Possessions form was incomplete, lacking a date and signature from the resident or responsible party. Although personal belongings were listed, there was no documented evidence that the form was completed upon the resident's readmission. LVN 1 confirmed the form's incompleteness during an interview and document review. For Resident 6, the inventory process was similarly flawed. The resident was unsure if her belongings were inventoried upon admission, and the form lacked a signature from the resident or responsible party. An inventory check revealed personal belongings not listed on the form, and the resident's clothing was unlabeled. LVN 2 verified these discrepancies during an observation and interview. The DON later acknowledged these findings.
Missed Neurology Consultation Due to Lack of Staff Assistance
Penalty
Summary
The facility failed to ensure that Resident 1 attended a scheduled neurology consultation appointment. Resident 1, who had mild cognitive impairment likely due to vascular dementia and frailty syndrome, was scheduled for a telemedicine neurology consultation. The appointment was to be conducted using Resident 1's telephone at the facility. However, at the time of the appointment, no staff member was present to assist Resident 1, resulting in the resident missing the scheduled consultation. The Case Manager acknowledged that she reminded Resident 1 of the appointment but was unavailable to assist at the scheduled time due to attending to other residents. The Case Manager did not delegate the task to another staff member, which led to Resident 1 not attending the neurology consultation. The Director of Nursing confirmed the expectation that a staff member should have been present to assist Resident 1 during the appointment. This oversight had the potential to delay Resident 1's plan of care.
Failure to Develop Individualized Care Plan for Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident with mild cognitive impairment likely due to vascular dementia. This deficiency was identified during a review of the facility's policies and procedures, which require the development of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. The medical record review revealed that the resident, who was admitted to the facility with primary issues of mild cognitive impairment and secondary issues of frailty syndrome, did not have a care plan addressing their cognitive impairment and vulnerability to cognitive decline. The deficiency was confirmed during an interview and concurrent medical record review with the Director of Nursing (DON), who verified that the resident's plan of care lacked a comprehensive and individualized approach specific to their cognitive condition. The resident's physician's progress note and order summary report indicated the need for a neurology consult for dementia, highlighting the resident's risk for cognitive decline, yet this was not reflected in the care plan. This oversight posed a risk for not providing appropriate and individualized care to the resident.
Failure to Document Treatment Administration
Penalty
Summary
The facility failed to maintain an accurate medical record for one of the sampled residents, specifically regarding the documentation of a treatment administered. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). The facility's P&P required licensed staff to document all services provided in the resident's medical record in accordance with state law and facility policy. However, the Treatment Administration Record (TAR) for a resident did not include the initials of the licensed nurse, indicating that the treatment was provided as ordered by the physician. The specific incident involved a resident who had an order for a warm compress to be applied to the right groin area four times a day. On a particular day, the TAR lacked documentation of the nurse's initials for two scheduled applications of the warm compress. During an interview, the Licensed Vocational Nurse (LVN) confirmed that she was responsible for the resident's care during the shift in question and acknowledged the missing documentation. The Director of Nursing (DON) also confirmed that the facility's policy required the nurse to document the treatment on the TAR to show it was administered as per the physician's order.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in multiple areas. In Medication Room A, an unsealed package of IV Statlock PICC Plus was found among other IV supplies. The Central Supply Room had various over-the-counter medications stored alongside oral medications, which was acknowledged by the CNA responsible for stocking the room. Additionally, the treatment cart contained expired dressings, unreadable labels on topical creams, and was not maintained in a sanitary condition, with items like a wet wound dressing box and stained drawers observed during the inspection. Two medication carts were found with sticky residue on medication bottles, and one cart contained an expired medication. Specifically, a bottle of ProStat liquid with an expiration date was found in Medication Cart A, and bottles of Milk of Magnesia and Geri Tussin with dried residue were found in Medication Cart C. These findings were verified by the respective LVNs during the inspections. Furthermore, a zinc oxide ointment was left unattended on top of a treatment cart in the hallway near Station 2, which was acknowledged by both an RN and an LVN. The facility's P&P on medication storage was reviewed, and it was noted that medications should be stored securely and only accessible to authorized personnel. The DON confirmed that the zinc oxide ointment should not have been left unattended and should have been stored properly in the treatment cart.
Food Preparation and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food preparation, storage, and sanitary requirements in the kitchen, which had the potential to cause foodborne illnesses to the residents. During an initial kitchen tour, several deficiencies were observed, including improperly disposed, labeled, and dated foods. Specifically, opened hamburger buns, carrots not in their original plastic bag, and grape jelly without received and used by dates were found. Additionally, pieces of ham were incorrectly labeled. These findings were verified by the Dietary Services Supervisor (DSS). The facility's policies and procedures (P&P) for food storage were not adhered to, as expired or outdated food products were not discarded as required. The USDA Food Code 2022 guidelines for cutting surfaces and can openers were also not followed. A heavily marred and scratched brown chopping board and a discolored countertop can opener were observed, both of which were confirmed by the DSS to be potential sources of pathogenic microorganisms transmissible through food. Furthermore, the facility failed to ensure that stainless steel mixing bowls, knives, and water pitchers were properly rinsed prior to use, as hard water marks were observed on these items. A knife and a blender were found with remaining water residue, and a clean spatula was placed on an unsanitized preparation area during pureed food preparation. These observations were verified by the DSS, who acknowledged that water remnants could contain bacteria and that utensils should be completely dry before use. Additionally, an inspection of Medication Cart C revealed containers of chocolate pudding and apple sauce with mismatched preparation dates on the lids and containers. The DSS and DSS in Training confirmed that dietary staff were responsible for checking these containers for proper preparation dates and that both dates should match.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices, leading to multiple deficiencies. LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date and placed spoons and a piston syringe directly on the bedside table without a barrier during medication administration for residents. LVN 4 did not follow Enhanced Barrier Precautions by failing to wear a gown during G-tube medication administration and did not perform hand hygiene or change gloves between tasks, using the same pair of gloves throughout the medication pass. Additionally, LVN 4 placed used spoons and a piston syringe plunger directly on the bedside table without a barrier. The facility also failed to sanitize Derma Klenz spray after use with residents, as observed with LVN 2 during wound care for two residents. The Derma Klenz spray was used as a community supply and was not cleaned before being returned to the treatment cart. This practice was confirmed by the Infection Preventionist (IP), who stated that the spray should have been cleaned to prevent the spread of infection. CNA 8 did not perform hand hygiene before handling clean towels, entering a resident's room, or donning new gloves, and failed to label a basin found on top of a toilet tank in a shared restroom. Additionally, CNAs 1 and 2 did not wear gowns while assisting a resident under Enhanced Barrier Precautions, despite the signage indicating the need for gowns and gloves during high-contact care activities. These failures were acknowledged by the Director of Nursing (DON) and other staff members during interviews.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure the residents' call light system was fully functional. Observations revealed that the call light system for two of the nursing stations was not audible, and specific residents' call lights were not answered promptly. For instance, Resident 61's call light was observed to be on but not audible on multiple occasions. The Maintenance Director confirmed that the call lights for certain rooms were not audible and mentioned that the facility had received recommendations to replace the entire call light system. Additionally, the survey team found that the call lights in several rooms were not working properly, as they did not produce audible sounds at the nursing stations. Furthermore, Resident 67 reported that a CNA did not return after initially attending to the resident, and the call light was not responded to when activated. The DON and Administrator acknowledged that the staff should have attended to Resident 67's needs. The facility's P&P required staff to respond to activated call lights, but this was not adhered to, leading to delays in addressing residents' needs. The Administrator stated that the call light system had stopped working the previous week, and manual bells were provided to residents only after the survey team meeting with the facility's management team.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was obtained prior to administering psychotropic medications to one of the six sampled residents. Specifically, Resident 26 was administered Seroquel XR 300 mg for schizophrenia and paroxetine 40 mg for depression without documented informed consent. The medical records showed that the informed consent forms for both medications were not signed by the physician, and the facility's verification form was incomplete, lacking verification of informed consent from the facility staff. Interviews with the LVN and the DON confirmed that Resident 26 had been receiving these medications since mid-February 2024. Both staff members acknowledged that the informed consent forms should have been signed by the physician and that the facility's verification form should have been fully completed. The facility's policies on informed consent and the use of psychotropic medications were not adhered to, resulting in the resident not being fully informed about their treatment.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure the accommodations of needs were met for one of 19 final sampled residents and two non-sampled residents. Specifically, the call lights were not within reach for two residents, and the call light was not answered promptly for another resident. These failures had the potential for the residents not getting their needs met timely. Resident 83 was observed with the call light behind the headboard of the bed, and Resident 84 had the call light clipped to the call light panel on the wall, making it inaccessible. Both residents were capable of using the call light and making their needs known. Additionally, Resident 67 reported that a CNA promised to check periodically but did not return, and the call light was not answered when pressed. The DON and Administrator acknowledged these findings and confirmed that call lights should be within reach and attended to promptly.
Failure to Implement Comprehensive Care Plan for IV Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving Vancomycin IV therapy. The resident was readmitted to the facility and had an order for Vancomycin IV solution to treat a UTI/sepsis. Despite the order being placed and the therapy starting, the care plan addressing the Vancomycin IV therapy was not initiated until several days later. This delay in care planning was confirmed through interviews with multiple registered nurses and the Director of Nursing, who acknowledged that the care plan should have been initiated as soon as the physician's orders were received. The medical record review showed that the resident's comprehensive care plan initially addressed IV therapy for a different antibiotic, Rocephin, but did not include a focused problem for Vancomycin IV therapy until much later. The failure to promptly update the care plan to include the new IV therapy meant that the resident's care was not appropriately individualized and monitored according to the facility's policies and procedures. This oversight had the potential to impact the resident's treatment and overall care quality.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident 84 was revised to reflect the treatment for both lower extremities for maintenance of skin integrity from cellulitis related to venous insufficiency. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy mandates the development and implementation of a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. However, the care plan for Resident 84 did not include the necessary interventions for the treatment of the left and right lower legs, despite physician's orders for specific treatments to address swelling and maintain skin integrity. During the review, it was found that Resident 84 had physician's orders to clean the left and right lower legs with soap and water, apply vitamin A and D ointment daily, and wrap with Kerlix and a cohesive bandage every day for 14 days. However, these interventions were not reflected in the resident's care plan. Interviews with an LVN and the DON confirmed that the care plan had not been updated to include these treatments. This oversight placed Resident 84 at risk for not having their specific care needs addressed appropriately.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide the necessary care and services to prevent the development of a wound for a resident observed for wound care. Specifically, the facility did not follow the physician's orders for treating the resident's right lower leg swelling. The physician's orders specified that the area should be cleaned with soap and water, vitamin A and D ointment should be applied, and the leg should be wrapped with Kerlix and a cohesive bandage. However, during an observation, an LVN used Derma Klenz wound cleanser instead of soap and water and did not place a cloth barrier or protective drape under the resident's foot during the wound care procedure. The LVN verified that he did not follow the physician's orders and acknowledged the mistake during an interview and medical record review. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency. This failure to adhere to the prescribed wound care protocol had the potential to contribute to the development or worsening of skin breakdown for the resident.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide the necessary care and services to prevent the worsening of a pressure ulcer for Resident 26. Specifically, the facility did not follow the physician's orders for wound treatment on Resident 26's right hip and right lateral malleolus pressure injuries. During a wound care observation, the LVN did not apply Santyl ointment to the right lateral malleolus pressure injury as ordered and used Derma Klenz instead of normal saline to cleanse the right hip pressure injury. Additionally, the LVN did not place protective pads under the pressure injury sites to protect the body sites and failed to prevent the resident's diaper from flipping back to the wound bed, which could lead to contamination and further complications. The LVN admitted to not obtaining the correct wound care supplies from the central supply and using what was available in the treatment cart. This deviation from the physician's orders and facility policies resulted in improper wound care for Resident 26, potentially exacerbating the resident's existing pressure ulcers. The facility's policy on clean dressing changes, which emphasizes the importance of following physician's orders and using appropriate protective measures, was not adhered to in this instance, leading to the identified deficiency.
Failure to Ensure Proper Positioning During GT Feeding
Penalty
Summary
The facility failed to ensure that Resident 53 was positioned safely at 30 to 45 degrees during enteral feeding via a gastrostomy tube (GT). On multiple occasions, Resident 53 was observed slouched in bed while the GT feeding pump was turned on, which was verified by LVN 1. Despite the resident's tendency to slide down the bed, there was no documentation of education or training provided to the resident's family members regarding the importance of keeping the head of the bed elevated during GT feeding. This failure posed a risk for developing complications related to GT, such as reflux and aspiration. The Director of Nursing (DON) confirmed that the head of the bed should be elevated at least 45 degrees during GT feeding and was unaware of Resident 53's positioning issues. The DON also acknowledged that if family members repositioned the resident, they should have been educated to maintain the proper bed elevation. The medical record review showed a physician's order for the GT feeding formula, Diabetisource AC 1.2, to be administered at 65 ml per hour for 20 hours daily. However, the facility did not ensure the resident was positioned correctly during the feeding process, leading to the identified deficiency.
Failure to Clean BiPAP Mask as per Policy
Penalty
Summary
The facility failed to ensure the BiPAP mask for Resident 74 was cleaned according to the facility's policies and procedures. The facility's policy, revised on 12/19/22, required the BiPAP equipment to be cleaned daily and weekly in accordance with CDC guidelines and manufacturer recommendations. However, during an interview on 4/9/24, Resident 74 stated that her BiPAP mask had never been cleaned since her admission. This was confirmed by LVN 3, who verified that there was no treatment order for the cleaning of the BiPAP mask. Resident 74's medical record showed she was cognitively intact and had the capacity to understand and make decisions, with a BIMS score of 14 on her MDS Quarterly assessment dated 1/17/24. The order summary for April 2024 indicated the use of a full mask BiPAP with specific pressure settings and oxygen requirements, but did not include any cleaning instructions for the mask. On 4/10/24, the DON acknowledged the findings and confirmed that a treatment order for cleaning the BiPAP mask was placed only after the issue was brought to their attention. The failure to clean the BiPAP mask as per the facility's policy had the potential to negatively impact Resident 74's medical condition. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to significant deficiencies in care. For Resident 7, who was readmitted with diabetic neuropathy and a coccyx pressure ulcer, the facility did not notify the physician about the resident's constant pain and did not obtain a pain medication order. Despite the care plan indicating the need for pain medication before wound care, Resident 7 was observed crying in pain during treatment, and no pain medication was administered until after the deficiency was noted by surveyors. Interviews with staff confirmed that the care plan was not followed, and the physician was not notified of the resident's pain levels during wound treatment sessions. For Resident 23, who was readmitted with orders for multiple pain medications, the facility failed to administer these medications according to the physician's orders. The resident, who was cognitively intact, frequently complained of pain and had to seek out nurses for pain relief. The medical record review showed that pain medications were given inconsistently with the prescribed pain levels, with instances of severe pain not being addressed appropriately. Interviews with nursing staff confirmed that the resident's pain management was not handled as per the physician's orders, leading to inadequate pain relief. These failures indicate a significant lapse in the facility's adherence to its pain management policies and procedures, resulting in inadequate pain control for the residents. The facility's policy required timely evaluation, notification, and administration of pain medications, which were not followed in these cases, leading to unmanaged pain and distress for the residents.
Failure to Monitor Fluid Restriction for Dialysis Residents
Penalty
Summary
The facility failed to ensure that two residents receiving dialysis services were monitored for fluid restriction as ordered. Resident 59, who was readmitted to the facility and later discharged to an acute care hospital, had a physician's order for a daily fluid restriction of 780 ml. However, the resident's intake and output records showed daily fluid intake ranging between 920 to 1260 ml, exceeding the prescribed limit. During an interview, LVN 5 admitted that the amounts documented were total fluids intake and did not specify how much of the nutritional supplement or other liquids were consumed. The RD also confirmed that she did not audit the total fluid intake and relied on nursing staff for this information. Similarly, Resident 61, who was admitted with end-stage renal disease and on fluid restriction per the dialysis center, had a daily fluid restriction of 600 ml. The intake and output records showed that the resident's daily fluid intake exceeded this limit on multiple days. LVN 5 could not locate the intake and output record and admitted that the documented amounts were total fluids without specifying the breakdown. The RD also stated that she did not audit the total fluid intake and relied on nursing staff for this information. Both cases highlight a failure in monitoring and documenting fluid intake accurately, posing a risk to the residents' care.
Inadequate Training and Improper Handling of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that nursing services were provided by appropriately trained staff, as evidenced by two CNAs (CNAs 9 and 10) improperly handling residents' oxygen equipment. CNA 9 was observed setting the oxygen rate for Resident 61, who had acute respiratory failure with hypoxia, asthma, and anxiety disorder. Similarly, CNA 10 was observed setting the oxygen rate for Resident 49, who had COPD exacerbation and acute hypoxic respiratory failure. Both CNAs admitted to setting the oxygen levels based on informal training from nurses, which was confirmed by the DSD as inappropriate since CNAs are not authorized to handle oxygen equipment. Additionally, the facility failed to provide adequate training on Enhanced Barrier Precautions (EBP) to CNAs 1 and 2. These CNAs were observed assisting Resident 35, who was on EBP due to the risk of MDRO transmission, without wearing the required gowns. Although the facility's IP stated that inservice training on EBP had been provided to all staff, the training records did not show that CNAs 1 and 2 had received this training. This lapse in training was confirmed by the IP during a document review and interview.
Failure to Accurately Document Controlled Medications and Timely Replace E-Kits
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of the residents, specifically in the accurate documentation and timely replacement of controlled medications. During an inspection of Medication Cart C, discrepancies were found in the controlled medication count sheets for two residents. For one resident, the count sheet showed eight tablets remaining for lorazepam 0.5 mg, but the medication bubble pack contained nine tablets. The LVN admitted to signing the medication out by mistake without administering it. Similarly, for another resident, the count sheet showed six tablets for clonazepam 2 mg, but the bubble pack contained seven tablets. The LVN confirmed that he had signed out the medication but did not administer it as the resident was sleeping at the time. These discrepancies indicate a failure to accurately document controlled medications as per the facility's policy and procedures (P&P). Additionally, the facility failed to ensure the timely replacement of oral and IV Emergency Kits (E-Kits) at Nursing Station A. The oral E-kit had a fill date of 4/4/24, and the IV E-kit had a pack date of 4/8/24. However, medications were removed from these kits on 3/27/24 and 3/31/24, respectively, and the kits were not replaced within the required 72-hour timeframe. The DON confirmed that the medications removed from the E-Kits were either not logged correctly or the replacement was not ordered on time. This failure to replace the E-Kits in a timely manner posed a risk for medication administration errors and lack of availability of emergency medications. The facility's P&P for controlled substance administration and accountability, as well as for emergency pharmacy service and E-Kits, were not followed. The discrepancies in medication counts and the delayed replacement of E-Kits highlight lapses in the facility's processes for managing controlled substances and emergency medications. These failures posed risks for medication diversion, administration errors, and unavailability of necessary medications in emergencies.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for a resident taking multiple medications, including gabapentin, methadone, and Dilaudid. The Pharmacy Consultant had recommended monitoring for central nervous system (CNS) and respiratory depression and placing hold parameters for the gabapentin medication. However, the facility did not follow up on these recommendations. The resident was readmitted to the facility and had physician's orders for these medications, but there was no documented evidence that the recommended monitoring or hold parameters were implemented. An interview with an RN confirmed that the Pharmacy Consultant's recommendations were not followed. The RN stated that the resident did not want any changes to her medications and wrote this in the follow-through section. However, there was no documented evidence to show that the resident was being monitored for CNS and respiratory depression or that the hold parameters for gabapentin were clarified with the attending physician. This failure had the potential to put the resident at risk for adverse consequences related to the medications.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below 5%, resulting in a medication error rate of 24%. During a medication administration observation, LVN 1 did not check Resident 53's heart rate before administering metoprolol, as required by the physician's orders. Additionally, LVN 1 administered a partial dose of vitamin C to Resident 53 due to medication residue left in the medication cup. Resident 53's physician's order specified that metoprolol should be held if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute, which LVN 1 failed to verify before administration. Similarly, LVN 4 administered partial doses of multivitamin with mineral, metoprolol, and famotidine to Resident 72 due to medication residue left in the medication cups. LVN 4 confirmed that Resident 72 did not receive the complete doses of these medications. The Director of Nursing (DON) was informed of these findings and acknowledged the medication administration errors.
Failure to Check Heart Rate Before Administering Metoprolol
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) administered medications without significant errors. Specifically, LVN 1 did not check Resident 53's heart rate before administering metoprolol, as required by the physician's orders. This oversight was observed during a medication administration session, where LVN 1 prepared and administered several medications, including metoprolol, without first verifying the resident's heart rate. Upon being instructed to stop, LVN 1 acknowledged forgetting to check the heart rate and subsequently performed the check before continuing with the administration. Resident 53's medical records indicated a physician's order to hold metoprolol if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. During a review and interview, both the Director of Nursing (DON) and LVN 1 confirmed the existence of this order and acknowledged the failure to adhere to it. The DON stated that she ensures licensed nurses are taught proper medication administration procedures during her observations.
Menu and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure that the menus were followed as per the nutritional needs of the residents. Specifically, the facility did not provide the correct number of cheese raviolis to two residents on a renal diet, serving nine and seven raviolis instead of the required ten. This discrepancy was confirmed by the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) during an interview, where it was revealed that the menu had not been updated to reflect the correct portion size for the type of ravioli being used. Additionally, the facility did not follow the menu for pureed breadstick and butter, using the wrong scoop size to serve the pureed bread to two residents. The Cook used a #16 scoop instead of the required #12 scoop, which was verified by the DSS during a trayline inspection. This error resulted in the residents receiving an incorrect portion size of their pureed breadstick and butter. Furthermore, the facility failed to provide butter or margarine, milk, and coffee to a resident as per the menu and tray ticket. The resident's family member noted the absence of these items, and the DSS confirmed the oversight during an interview. Another resident received two desserts instead of one, despite not requesting the extra portion. This was verified by both the resident and the Licensed Vocational Nurse (LVN) who initially claimed the resident had asked for two desserts but later confirmed the resident did not make such a request.
Facility Failed to Ensure Palatable Food
Penalty
Summary
The facility failed to ensure the food served was palatable, specifically the roast beef, which was found to be tough and hard to cut or chew. This issue was observed during a dining observation on 4/9/24, where three residents (Residents 78, 27, and 392) were served roast beef that was difficult to cut and chew. Resident 78's family member attempted to cut the roast beef several times but was unsuccessful. Similarly, Resident 392 and Resident 27 both reported that the roast beef was very hard and not edible, respectively, and were observed struggling to cut the meat with a knife. The Dietary Services Supervisor (DSS) verified these findings during a concurrent interview and observation. The DSS confirmed that the roast beef served to the three residents was indeed tough and hard to cut. The residents involved were on regular diets, with Resident 78 on a no added salt (NAS) regular diet. The failure to provide palatable food had the potential to affect the residents' nutritional status, as they might not eat the food served.
Failure to Provide Properly Pureed Food
Penalty
Summary
The facility failed to ensure that residents on a pureed diet were provided with food prepared in a form to meet their individual needs. During an observation of pureed food preparation, it was noted that the vegetable lasagna contained tiny carrot bits after being processed, which was verified by the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD). The facility's policy on texture-modified diets specifies that pureed foods should be smooth with no lumps to eliminate the chewing phase for residents with severe chewing and/or swallowing problems. The presence of tiny carrot bits in the pureed vegetable lasagna could pose a choking hazard, as confirmed by the RD. The facility's Diet Type Report indicated that 10 residents were on a pureed diet texture at the time of the observation.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident 543, who had a documented dislike for all dairy products. Despite this, the resident was served pureed breadstick and butter with milk. This discrepancy was observed during a pureed food preparation session where the Dietary Cook added milk to the breadstick and butter mixture. The tray cart was stopped before distribution, and it was confirmed that Resident 543's lunch tray ticket indicated a dislike for all dairy products, yet the meal included milk. The resident's family member confirmed that while the resident did not have allergies to dairy products, they did not want milk or milk products included in the resident's meals. The medical record review for Resident 543, who was admitted to the facility on an unspecified date, showed no additional directions for the resident's pureed diet beyond the dislike for dairy products. The Diet Type Report completed by the facility also did not provide further instructions. The deficiency was identified during an observation on 4/10/24, where the Dietary Cook and the DSS were present. The RD interviewed the resident's family member, who reiterated the preference against milk or milk products, highlighting the facility's failure to adhere to the resident's documented food preferences.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For Resident 31, the facility did not ensure complete documentation for ADL-Bed Mobility Intervention/Task. The medical record review showed missing documentation for several dates in March and April 2024, both for the night and day shifts. The Medical Records Director and the Director of Nursing (DON) verified the missing documentation and acknowledged the oversight during interviews conducted on 4/12/24. For Resident 23, the facility failed to ensure that informed consents for medications were signed by the physician. Resident 23, who was cognitively intact, received buspirone and citalopram medications without the required physician-signed informed consents. The review of the Medication Administration Record (MAR) confirmed that the medications were administered from 3/19 to 4/11/24. Both RN 1 and the DON verified the absence of the physician's signature on the informed consents during interviews conducted on 4/11/24 and 4/12/24, respectively.
Failure to Maintain Accurate Quality Control for Glucometer
Penalty
Summary
The facility failed to ensure that one glucometer (Glucometer C) from one of five medication carts (Medication Cart C) was maintained in safe operating condition. During an inspection, it was observed that the test strips in use had an open date of 4/11/24 and a specific lot number, but the quality control log for the same date did not match the test strips' lot number and control solution ranges. The log indicated a different lot number and control ranges, which did not correspond to the test strips found in the medication cart. LVN 3 confirmed that the quality control checks were performed by the night shift nurse and acknowledged the discrepancies in the documentation and the actual test strips present in the cart. The Assure Platinum Blood Glucose Monitoring System Instruction Manual requires that a control solution test be performed whenever a new bottle of test strips is opened to ensure the meter and test strips are working correctly. However, the facility's records did not reflect this practice accurately. The failure to maintain accurate records and perform proper quality control checks had the potential to result in inaccurate glucose readings for residents requiring glucose monitoring. LVN 3 verified that there was no other bottle of test strips in the cart to match the documentation, indicating a lapse in following the required procedures for quality control checks.
Failure to Promote Resident Dignity During Feeding
Penalty
Summary
The facility failed to promote the dignity and respect for Resident 65. During a lunch meal observation, CNA 7 was observed standing over Resident 65 while assisting and feeding him. Resident 65, who had the capacity to understand and make decisions, stated he needed assistance when eating during meal times. CNA 7 acknowledged that he should not have stood over the resident while feeding him. Both RN 2 and the DON confirmed that CNA 7 should have been seated and at eye level with Resident 65 during feeding times.
Failure to Investigate Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance for one of the sampled residents. Medical record review for Resident 87, who had diagnoses including post status multiple falls, episodes of delirium, anxiety, and generalized muscle weakness, showed that the resident did not have the capacity to understand and make decisions. On a specific date, Resident 87's responsible party (RP) verbalized concerns about staff not answering call lights and residents almost falling. Despite these concerns, there was no documented evidence that the facility addressed the RP's grievance. During an interview and medical record review with the Director of Nursing (DON), it was confirmed that no investigation follow-up was documented for the RP's concern.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
